Massage Therapy Client Intake Form
Please complete this form to help us provide a safe and personalized massage experience.
Appointment
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Massage Modalities
Please Select
Swedish
Deep Tissue
Trigger Point
Aromatherapy
Reflexology
Prenatal
Have you received professional massage therapy before?
*
Yes
No
What are your goals for today's massage?
*
Relaxation
Pain Relief
Stress Reduction
Injury Recovery
Increase Flexibility
Other
Do you have any of the following health conditions?
High Blood Pressure
Heart Condition
Diabetes
Allergies
Recent Surgery
Skin Conditions
Pregnancy
None of the above
Other
If you checked any conditions above, please provide details (including medications or allergies injuries and surgeries or anything specific happening in your body.)
Are there any areas you would like the therapist to focus on or avoid?
Back
Neck
Shoulders
Legs
Arms
Feet
No Preference
Other
Preferred pressure level
Light
Medium
Firm
No Preference
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
Desired Duration of Experience
Please Select
30 mins-$55
60 mins- $75
90mins- $95
Submit Intake Form
Submit Intake Form
Essential Oils Optional (No additional Charge)
Please Select
Lavender
Peppermint
Frankincense
Rosemary
Cherry
Date
-
Month
-
Day
Year
Date
Payment Methods
Massage Therapy Terms and Conditions
1. Appointment Policy: If you need to cancel, please notify me at least 2 hours prior to your appointment. Late cancellations or no-shows should be avoided. 2. Cancellation Policy: Cancellations must be made at least 24 hours in advance. 3. Health Disclosure: Clients must disclose any medical conditions, allergies, or injuries prior to treatment to ensure safety. 4. Consent: By receiving massage therapy, you consent to the treatment and acknowledge understanding of the techniques used. 5. Confidentiality: All client information is kept confidential and will not be shared without your consent. 6. Payment: Payment is due at the time of service. We accept cash, credit cards, Zelle (4802740396), and CashApp (VOlivas93). 7. Hold Fee: A $20 hold fee is required to secure your appointment. 8. Liability: Massage therapy is not a substitute for medical treatment. The therapist is not responsible for any adverse reactions.
Should be Empty: