New Client Intake Form

New Client Intake Form

Welcome!
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Referred By
Is there anywhere you prefer not to be touched? (feet, neck, face, etc.)
Optional: Date of Birth (If you'd like a birthday discount!)

MonthDayYear
Date
Which type of pressure do you generally prefer?

Light/lymphatic (relaxation focus)MediumFirm (address the knots, but be nice about it!)
I consent to the following as needed:

Light stretching of the arms/legsTherapeutic compressions of the glutesFace massageHead massage
Do you have sensitivities to vibration, heat, or sound?

YesNo
What are your goals for seeking massage therapy?
Health Information
Are you currently taking any medications? If yes, please list:
Any allergies? (oils, fragrances, nuts, etc.)
Are you pregnant?

YesNo
Are you currently experiencing any of the following?

Area of swellingBeck/neck problemsContagious conditionDecreased sensationFibomyalgiaHeadachesOsteoporosisSciaticaBruise easilyHeart condition or pacemakerSeizuresVertigo/dizzinessVision problems
Do you have any skin conditions? (Warts, rashes, skin growths, etc).
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 understand there is no sexual component to massage therapy whatsoever and acknowledge that any insinuation, joke, or inappropriate request or touch will result in the termination of my session and payment in full plus a $100 fee. I agree to inform my massage therapist of any health or medical changes. I understand my therapist will do their best to keep me warm, comfortable, and appropriately draped, as required. I agree that it is my responsibility to consult a licensed medical practitioner for any physical or mental complaints I may have. I understand massage and sound therapy are not intended to replace any currently prescribed medical treatments as ordered by my physicians, nor any other medical care I have, or may be advised to seek by them.
I understand that if I cancel or request to reschedule less than 12 hours before my scheduled appointment, a $50 cancellation fee may be charged. I acknowledge that this fee may be waived at the provider’s discretion in the case of emergencies or illness. I understand that failing to attend my appointment without giving any prior notice will be considered a “no-show,” and I may be charged up to the full cost of the scheduled service.

By checking this box, I confirm that I have read and accept the terms of these policies.
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New Client Intake Form

Health Information