Massage Therapy Intake Form
Welcome to Health & Light Institute. To provide you with the best experience, please complete the following intake form. All information is confidential.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date of Birth
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
Please enter the Full Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referral Information
How did you hear about our practice?
Medical Information
Have you ever received professional massage therapy before?
*
Yes
No
Are you currently under medical supervision?
*
Yes
No
If yes, please describe...
Do you have any skin allergies or sensitivities:
*
No
Yes
If yes please describe...
Do you have any of the following medical conditions?
*
Cardiovascular issues
Skin conditions
Joint problems
Recent surgeries (within the last 6 months)
Allergies
High/low blood pressure
Diabetes
Pregnancy
Other
If Other, please describe...
Please list any medications you are currently taking:
Please list any areas of pain, tension or any other issues you'd like to address during the session:
*
Massage Preferences
Preferred massage pressure:
*
Light
Medium
Firm
Deep
Other
If Other, please clarify
Are there areas you would prefer NOT to be massaged?
*
Yes
No
If yes, please specify any areas you'd rather not be massaged...
Preferred Massage Type
*
Swedish
Esalen Massage
Hot Stone
Aromatherapy
Energywork
Prenatal
Other
If Other please describe...
Consent
I understand that the massage therapist is providing services for the basic goal of relaxation and/or the relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist to adjust the technique. I understand that massage should not be considered a replacement for medical examination, diagnosis, or treatment. I have stated all my known medical conditions and have answered all questions honestly. I agree to keep the therapist updated on any changes to my medical profile and understand that there shall be no liability on the therapist's part should I forget to do so.
Signature
*
Date
*
/
Month
/
Day
Year
Date
Once you've completed the form, please click Submit.
We look forward to serving you!
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