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
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: