Michelle's Hidden Spa Massage Therapy Client Intake

Date

Full Name

First NameLast Name

Referred By:

Google, Facebook, Yelp, etc.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

E-mail

Birth Date Month & Day

Emergency Contact

Phone Number

Area CodePhone Number

Occupation

Where are you having pain or tightness?

Describe Onset of Discomfort or Pain

List all related treatments received for this injury and did it help

If you could waive a magic wand how would you like to feel within one month?

Is there anything that you do that creates, increases or decreases pain?

What activities/hobbies do you enjoy?

Any areas you do NOT want massaged?

Any special requests today? (CBD, body scrub, foot & hand treatment, aromatherapy, mini facial)

Any scents you absolutely love or dislike?

What kind of pressure do you like? Light to firm pressure, deep

Medical, Health, Bodily Conditions: Is there anything I need to know before we get started? The more I know, the better your experience. (Please List: allergies, sensitivities, pregnancy, stress level, health issues, diabetic, medications, metal plates.

What did you LOVE about your last massage and what could you have lived without?

Anything else you want to share? I love learning about my clients as it helps me provide superior customer service.

I agree

*Please note any additional information that may be of importance to your Licensed Massage Therapist regarding the spa treatment you will be receiving.

After hitting submit, please go ahead and book your appointment. You do not need to wait for me to respond to this form. All booking is done online at www.michelleshiddenspa.com Click on any of the Book Now Buttons.

Signature*

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Date