Massage Intake Form

Massage Intake Form

All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Date

MonthDayYear
Date
Full Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Client information are confidential. 24 hour cancellation notice is required to avoid cancellation fee. Client Agreement: I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction. I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Health Information