i. Studio Recove Intake Form

Studio Recove Intake Form
Welcome to Studio Recove, where massage is more than relaxation — it’s body science, touch artistry, and sacred recovery.

Before your first session, this confidential intake form helps me understand your unique needs, goals, and health history. Your body’s story guides every decision — from the techniques chosen to the pressure applied — ensuring a safe, effective, and deeply personalized experience.

Please answer each question honestly and completely. Every detail matters: your comfort, your safety, and your results depend on it. This information remains private and protected in accordance with HIPAA compliance standards.

By taking a few moments to complete this form, you help me create the perfect foundation for your care — where restoration begins not just with touch, but with understanding.

PERSONAL INFORMATION
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Age*
Phone Number*
Please enter a valid phone number.
Client Email*
example@example.com
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
How did you find us?*
Please enter your Groupon voucher code below. (You will still need to bring it to your appointment for checkout.)
If someone referred you, please specify their name below.

MEDICAL HISTORY

Please list any and all past injuries and year of incident over the last 20 years:

	Type of Injury (ex. sprain, strain)	Place of Injury (arm, ankle)	Year
Injury 1
Injury 2
Injury 3
Injury 4

Please list any and all past injuries and year of incident over the last 20 years:*

	Type of Surgery	Place of Surgery (arm, ankle)	Year
Surgery 1
Surgery 2
Surgery 3
Surgery 4

Please provide any and all additional information you were unable to provide above.

MEDICATIONS

Please list any and all medications

	Name	Dosage	Frequency
Med 1
Med 2
Med 3
Med 4

Please provide any and all additional information you were unable to provide above.

Confirmation
Signature*

Clear
Should be Empty: