Massage Intake form R&M

Welcome! I would like your appointment to be as pleasant and comfortable as possible. If at any time you have questions regarding your session, please let me know.
Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
Occupation
Referred by
Emergency Contact (Name, relationship and #)
What pains/problems/goals are you looking to solve, short or long term?
YESNO
YESNO
If yes, Please list name(s) and reason for medication:
Please describe any medical conditions that I should be aware of:
skin rashcold/fluopen cutssevere painanything contagiousinjuries/bruises
Contact LensesHearing AidHairpieceFull/Partial Dentures
List any known allergies
Describe and/or indicate area(s) of discomfort on image below.
Annotate Image
Read and sign: I understand that massage is for the purpose of relaxation, stress reduction, and relief or muscular tension, and should not be construed as a substitute for medical care.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: