New Client Intake Form

Name*

First NameLast Name

Email

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referred By

Date of Birth (If you'd like a birthday discount)

Date

Have you received massage therapy before?*

YesNo

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?*

YesNoUnsure

What are your goals for seeking massage therapy?

Are you currently taking any medications? If yes, please list:

Do you have any allergies? (oils, fragrances, nuts, etc.)*

Are you pregnant?

YesNo

Are you currently experiencing any of the following?*

Do you have any skin conditions? (Warts, rashes, skin growths, etc). *

Anything else you'd like me to know before your session?

I acknowledge that I have been informed of the potential benefits and risks associated with massage therapy and affirm that I have completed this form truthfully and to the best of my knowledge. I understand that massage therapy provided is strictly professional, with no sexual component, and that any inappropriate behavior—including insinuations, jokes, requests, or physical contact—will result in immediate termination of the session. In such a case, I agree to pay the full session fee plus a $100 penalty.

I agree to promptly inform my massage therapist of any changes in my health or medical condition. I understand that the therapist will make every effort to ensure my comfort by maintaining warmth, proper draping, and respecting my preferred level of pressure. I also acknowledge that this practice does not provide deep tissue techniques that follow a "no pain, no gain" approach.

I recognize that massage and sound therapy are complementary therapies and are not substitutes for medical treatment or counseling. It is my responsibility to seek advice from licensed healthcare providers or mental health professionals regarding any physical or psychological concerns I may have.

By signing, I consent to receive massage therapy with the understanding of these terms and agree to hold the therapist harmless for any unforeseen adverse effects resulting from treatment.

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.

Please sign here:

New Client Intake Form

Health Information