Client Intake & Consent Form.

Client Intake & Consent Form.

Confidential Wellness Intake FormPlease complete this form before your session to help us tailor your experience.
Personal Information
Full Name

First NameLast Name
Mobile number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Occupation
Health & Medical Information
Health conditions / concerns

None
Current medication
Allergies to oils, creams, or lotions
Additional medical information
Session Information
What is your main goal for today's session?
Areas of tension or discomfort
Pressure preference
Have you received massage therapy before?
Are there any areas you would like avoided?
Consent Section
Consent to Accuracy of Information
Understanding of Therapy Limitations
Pain or Discomfort Notification
Understanding of Treatment Safety Limits
Consent to Treatment
Signature
Digital Signature
Date

MonthDayYear
Date
Should be Empty: