New Client Intake Form
Thank you so much for your interest in booking with me! 🤍 I truly appreciate you taking the time to fill out my form. I’ll be in touch soon to discuss your massage needs and find the perfect appointment for you. I look forward to helping you relax, reset, and restore! ✨
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
Please enter a valid phone number.
Format: (000) 000-0000.
Massage goals or objective?
Relaxation & Stress relief
Reduce Pain and Discomfort
Post- workout Recovery
Unsure
Massage duration
Please Select
60 minute
90 minute
120 minutes
Do you have any medical conditions we should be aware of?
Are you currently taking any medications?
Are you currently pregnant?
Yes
No
Please list any allergies (including lotions, oils, scents):
What areas would you like to focus on or avoid during your massage?
How did you hear about us?
Please Select
Friend/Family
Online Search
Social Media
Walk-in
Other
Signature (I consent to receive massage therapy and have provided accurate information.)
*
Submit
Submit
Should be Empty: