Intake Form

Intake Form

This space was made with you in mind. Take a moment to fill out this form so I can better understand your needs, preferences, and how I can show up for you through this session. Everything shared here stays between us—confidential, intentional, and held with care.
Full Name

First NameLast Name
Personal info

Phone numberEmail address
Birth date Height/Weight
Occupation
Emergency contact

Their nameTheir phone number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- Do you have any medical conditions or allergies we should be aware of?
- Are you on any medications? If yes, please list names and use:
- Are you pregnant? If yes, how far long?
- Indicate any of the following that may apply to you.
- Explain any conditions you have marked above:
- What areas of your body would you like us to focus on during the massage?
- Have you had a professional massage before?
- What type of pressure do you prefer
- What are your goals for this session?
- Additional Comments or Requests
- How did you hear about us?
- HIPPA
  
  All information shared is confidential and protected in compliance with HIPAA. Your privacy and trust are deeply respected here.
- By signing below, I confirm that all information provided is accurate to the best of my knowledge and agree to notify Melanie Vera-Diaz of any changes. I also give full consent to receive massage services under her care.
- Should be Empty:

HIPPA