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 Name
Last Name
Personal info
Phone number
Email address
Birth date
Height/Weight
Occupation
Emergency contact
Their name
Their phone number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
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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.
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint replacements
High/Low blood pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood clots
Numbness
Sprains or Strains
Explain any conditions you have marked above:
What areas of your body would you like us to focus on during the massage?
Back
Neck
Shoulders
Legs
Arms
Feet
Full Body
Have you had a professional massage before?
Yes
No
What type of pressure do you prefer
Light
Medium
Deep
What are your goals for this session?
Additional Comments or Requests
How did you hear about us?
Instagram
Tiktok
Google
Word of mouth
Returning client
Other
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.
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