Massage Therapy Client Intake & Consent Form
Complete your contact details, health history, preferences, and consent to receive massage therapy.
Client Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any current or past medical conditions?
*
Yes
No
If yes, please explain your medical conditions.
Are you currently under the care of a medical or mental healthcare provider?
*
Yes
No
Are you currently taking any medications?
*
Yes
No
If yes, please list your medications.
Do you have any allergies?
*
Yes
No
If yes, please explain your allergies.
Have you had any recent injuries or surgeries?
*
Yes
No
If yes, please explain your recent injuries or surgeries.
Are you currently pregnant?
Yes
No
What level of pressure do you prefer?
Light
Medium
Firm
What are your goals for today's massage?
Relaxation
Stress Relief
Muscle Tension
Pain or Discomfort
Other
Please describe any areas of pain or tension.
Are there any areas you would like to avoid during your massage?
Is there anything else regarding your health or comfort that I should know before your massage?
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Submit Form
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