Client Intake Form

Massage Information
NoYes
If yes, how recently?
RelaxationAlleviate PainSpecific ProblemOther
LightMediumFirm
Additional Notes / Comments
By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.
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Date of Appointment*

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Signed On*

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Emergency Contact Information