New Client Intake Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

YYYY

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Your gender

What are your Pronouns?

Who can I thank for referring you?

Are you currently experiencing any of the following conditions?

Recent Injury/Accident

Dizziness

Fever

Infection

Flu/Cold

Open Sore/Wound

Nausea

Contagious Disease

Please list any conditions that apply to your current health or with which you've had significant history

Please describe current conditions, past surgeries, major injuries/accidents/illnesses, or medical conditions

Please list any areas where you currently or habitually experience pain or tension

Please list any allergies or chemical sensitivities

Are you currently pregnant or attempting to conceive?

If yes, when are you due?

YYYY

Please list any regular exercise, sports, or movement practices you participate in

Please list any medications (prescription or otherwise) or supplements you currently use

Please list any other information you feel is important

Terms & Conditions

I understand that massage therapy involves neither diagnosis nor treatment of any condition, and is not a substitute for medical care. This session will consist of only relaxation and therapeutic massage techniques; draping will be used at all times; neither my breasts (if applicable) nor genital areas will be massaged. If I am uncomfortable for any reason I may request to end the session, and the session will be ended. I understand the risks of massage therapy, including but not limited to superficial bruising, soreness, and exacerbation of undiscovered injuries, and I release the company and massage therapist of all liability in the case of such injuries. I have clearance from my physician to receive massage therapy, and I agree to disclose all medical conditions or medications now and in the future as changes occur. Cancellation Policy: 24 hours notice is required for all cancellations and reschedules. If I cancel or reschedule an appointment with less than 24 hours notice, I agree to pay 50% of scheduled services (before any discounts) as cancellation fees. If I no show an appointment, I agree to pay 100% of scheduled services (before any discounts) as cancellation fees. Please type your full name below to acknowledge the following: All of the information I have provided is true and accurate to the best of my knowledge, and I have read and the cancellation policy.

Date

YYYY

New Client Intake Form

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