Client Request Form

Client Request Form

This is a client REQUEST form. Submitting this form gives me an idea and overview of what you are looking for in massage therapy and helps me determine if we should move forward. Any Information provided below is confidential and will be kept between you and your massage therapist. New clients are REQUIRED to fill out this form. Please Fill Out and answer all questions below:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How would you like to be contacted? Text, Phone Call, Social Media- Please provide your number below or IG handle:
What is your occupation?
Have you ever had a professional massage? (If so, how long ago?)
Do you have any allergies to any oils, lotions, fragrances etc.?
Have you ever had a surgery? (If so, where and how long ago?)
Do you have any difficulty lying on your back, side or front?
Medical Conditions, Medications or Concerns:
Are you feeling any pain, discomfort or tension? If so, please name areas below:
Pain/Tension Scale:

1

2

3

4

5

1 is No Pain, 5 is Painful
Please Select Areas you’d like to work on for this session:
What is your Goal for this session?
What city are you located in?
County:
Please Select Appointment Date and Time that works best for you:
How did you find me?
By signing below I acknowledge:

• Massage Therapy is a therapeutic and holistic way of relief and wellness. Prescribing and Diagnosing is NOT in my scope of practice.
• This is a Client REQUEST Form and will be reviewed. Please allow 24-48hrs for a response time. A message will be sent back to you accepting/denying your request.

Please print full first and last name below:
First Name Last Name
Should be Empty: