Massage Intake Form

Wellspring Health Center|Massage Client Information

Date*

Date

Name*

First NameLast Name

MaleFemale

Age

Birthdate*

Date

Address*

Address

Street Address Line 2

City

Zip

Email*

example@example.com

Primary Phone#*

Occupation

Are you pregnant?*

YesNo

Due Date

Date

How did you hear about Wellspring?*

Health Insurance Plans

Please circle the areas you would like the massage therapist to focus on:

What are your chief complaints*

When did these symptoms start

What treatment have you had for these symptoms?

Is this the result of an accident or injury?*

YesNo

Accident or injury date:*

Date

Describe accident or injury:*

Current Health Conditions

Current Medications

Known Allergies

Any allergies to lotions, oils, or essential oils?*

YesNo

Describe lotion/oil/essential oil allergies:

Do you have any pain or mobility issues that make it hard to do any of the following activities?

What are your top 1 - 2 goals for receiving massage therapy?

Would you like information about any of these Wellspring services?

Massage SpecialsWellness ClassesHolistic Physical Therapy

A. I understand that the massage given to me by a certified massage therapist at Wellspring Health Center is for stress reduction, pain reduction, relief from muscle tension, or increasing circulation.

B. I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, non are spinal manipulations part of massage therapy.

C. I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.

D. I have stated all my known physical conditions and medications, and I will keep the massage therapist updated on any.

E. I acknowledge that I have been informed of Wellspring Health Center’s cancellation and no-show policies and agree to abide by them. The full policies are available at https://wellspring-hc.com/massage-appointment-policy/

Signature*

Date*

Date