Massage Intake Form

Massage Intake Form
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred by

First NameLast Name
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone NUmber
Please enter a valid phone number.Format: (000) 000-0000.
Date of Initial Visit

MonthDayYear
Date
How would you rate your general health?

ExcellentGoodFairPoor
Have you had a professional massage before?

YesNo
Date of Last Treatment:
How did you hear about us?

At Massage By K & Wellness At Wildwood, our goal is to support your well-being through thoughtful, personalized bodywork. Before we begin, please take a moment to read and acknowledge the following.

- I understand that massage thearapy is intended to support relaxation, reduce muscle tension, and encourage overall wellness.

- I know that massage therapists do not diagnose medical conditions or replace that care of licensed healthcare provider.

-It's my responsibility to share any health concerns, injuries, or changes in my condition so the therapist can safely tailor the session to my needs.

- I'll speak up at any time if something feels uncomfortable or needs adjustment.

- I understand that any inappropriate behavior will result in the session ending immediately.

If receiving cupping or Thai Massage:

- I understand that cupping therapy may leave temporary marks or discoloration on the skin that typically fade within a few days to a week.

- I understand that Thai massage involves movement and stretching techniques, and will communicate any discomfort or limitations I may have.
By signing below, I give my consent to receive massage therapy (including cupping or Thai massage if selected), and confirm that I understand and agree to the above terms.
Should be Empty:

**Please mark any of the following conditions you may currently have.