New Client Intake Form

Full Name

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

MonthDayYear
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Appointment Goals

What brings you in for your massage?
Please select all that apply

Other

Massage Therapy Consent
I understand that massage therapy is intended to support relaxation, mobility, and muscular comfort and is not a substitute for medical diagnosis or treatment. I have disclosed relevant health information and will inform my therapist of any changes. I understand that results are not guaranteed and that temporary soreness or sensitivity may occur.

I may request changes to pressure, positioning, draping, techniques, or areas treated and may pause or end the session at any time. Still Hour Studio or the therapist may modify or discontinue treatment when massage may be unsafe or inappropriate.
By checking the box below, I confirm that I have read, understand, and consent to massage therapy.
Consent for Gluteal Work
Gluteal work may be recommended to address tension involving the hips, lower back, or legs. The area will remain professionally draped, and no contact will be made with intimate areas. Consent may be changed or withdrawn at any time.
Please indicate your preference:
Client initials:
Studio Policies
I acknowledge and agree to Still Hour Studio’s cancellation, rescheduling, late-arrival, no-show, deposit, and payment policies. Appointments canceled with less than 24 hours’ notice, or missed without notice, may be charged 25% of the scheduled massage price. Deposits are refundable when cancellation is made at least 24 hours in advance. Appointments may be rescheduled without penalty when at least 18 hours’ notice is provided. Late arrival may shorten the session without reducing the scheduled price.
By checking the box below, I confirm that I have read, understand, and consent to Studio Policies.
Final Acknowledgment and Signature
I certify that the information provided is accurate and complete. I understand that withholding relevant information may affect the safety or effectiveness of my session. I acknowledge that massage therapy is professional and nonsexual and that inappropriate conduct will result in immediate termination of the session, with payment due in full.

By signing electronically, I confirm my informed consent and agreement to the acknowledgments and policies above. I understand that I may withdraw treatment consent at any time, but financial obligations already incurred remain applicable.
Client name:
Date
Client Signature
Should be Empty:

Appointment Goals

Health History

Areas of Focus

Allergies and Sensitivities

Appointment Preferences

Massage Therapy Consent

Consent for Gluteal Work

Studio Policies

Final Acknowledgment and Signature