Client Intake Form
All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Full Name
First Name
Last Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
How did you find us?
1. List Areas of Discomfort or Pain
2. Describe Onset of Discomfort or Pain
3. Rate of Pain Today
Please Select
1 - very little
2
3
4
5
6
7
8
9
10 - very painful
4. List any injuries or surgeries and the approximate date (or if you are pregnant)
MASSAGE POLICIES AND CLIENT AGREEMENT.
BY SUBMITTING THIS FORM, YOU ARE AGREEING TO THE MASSAGE POLICIES AND CLIENT AGREEMENT.
*
I agree
Submit
Should be Empty: