Monarch Massage Client Intake

Monarch Massage Client Intake

Standard online client intake form for Monarch Massage. Please complete all required fields before your appointment.
Client Information
Full Name

First NameMiddle NameLast Name
Date of Birth

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

Street Address

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

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Health & Care Status
Are you currently under the care of a physician?
If yes, please describe the condition
Have you had massage therapy before?
If yes, when was your last session?
Session Goals & Concerns
What are your goals for this massage session?
Describe areas of concern
Pain Scale – Average pain level
Health Conditions
Health conditions

Other
Other health condition, please describe
Consent & Release
I have read and understand the consent & release statement above.
Signature
Signature Date

MonthDayYear
Date
Office Use Only
Office Use Only – Therapist
Office Use Only – Session Type
Office Use Only – Notes
Should be Empty: