Massage Client Intake Form

Massage Client Intake Form

Thank you for booking a massage with us. Information collected about new clients is confidential and it will be treated accordingly. Fields marked with * are required.
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date (if under 18, parent consent form is required)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Have you had a professional massage in the past?

YesNo
Do you have any allergies? (oils, lotion, fruit, nuts, skin, etc.)

YesNo
If so, explain:
List any recent injuries/accidents/surgeries
Are you pregnant?

YesNo
Pressure Preference

Light/MeditativeMedium/ModerateDeep/Trigger Point
Please check any that apply to you

ArthritisAsthmaCancer (if currently in treatment, medical consent is required)DiabetesEczemaDiagnosed FibromyalgiaHeadachesHigh Blood PressureInsomniaJoint PainJoint ReplacementNeuropathySprains/StrainsStressTendinitisOsteopenia/OsteoporosisDiagnosed Disc HerniationBlood Clots (if checked, medical consent is required)Varicose VeinsNone
Other:
How did you find me?
Comment or question:
Massage Policies:

Client services and chart information are confidential.
24 hour cancellation notice is required to avoid being charged for your session

You will have a consultation with your therapist to discuss your session

I understand that my therapeutic massage therapist or I may end the session at any time for any reason

Inappropriate behavior will not be tolerated and will result in the immediate termination of the massage and the full amount of the service will be charged.
Client Agreement:
I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform bone manipulation. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive therapeutic massage as a form of therapy. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist, so they adjust. I have stated my pertinent medical conditions and will update the massage therapist of any changes in my health status. I understand that my failure to do so may pose a threat to my health and/physical well-being and I hold harmless Massage by Daniel and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.
Date*

MonthDayYear
Date
Client Signature*

Clear
Should be Empty:

Massage Client Intake Form

Massage Policies:

Client Agreement: