Massage Therapy Intake Form for First-Time Clients 👐✨

White Orchid Massage & Wellness Intake Form

Please provide your details and health information to help us prepare for your session.
Full Name*

First NameLast Name
Date of Birth*

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently experiencing any of the following?

Muscle pain or tensionJoint painHeadachesStress or anxietyRecent injuryOther
Please list any medical conditions or allergies
Are you currently taking any medications?

YesNo
If yes, please list your medications
Are you currently pregnant

YesNo
Do you have any areas you would like to focus on or avoid during your massage?
Preferred massage pressure

LightMediumFirm
I have read the Policies as listed (https://www.whiteorchidmassagewellness.com/private-therapeutic-massage).
Do you agree to these policies?*

YesNo
Is there anything else we should know to make your session comfortable?
Should be Empty:

White Orchid Massage & Wellness Intake Form