Massage and bodywork Intake Form
Client Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Health Data
Date of Birth
-
Month
-
Day
Year
Date
Do you have any allergies?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing? (Female only)
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
I, undersigned, agree with the following statements:
I authorize this massage spa clinic/center to perform the treatment or necessary procedure for my child.
I authorize the use of lotion, oil, or ointments to my body.
I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release this massage clinic for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
I am comfortable with foot, glute, and chest work.
I understand that the massage can be stopped at any time for inappropriate behaviors or comments.
Date Signed
-
Month
-
Day
Year
Date
Client Signature
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