Intake & Consent Form

Please take a few moments to fill out this form with complete and accurate information to the best of your knowledge.

First name

Last name

Birthday

Month

Day

Year

Email

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Referred By:

Emergency Contact & Phone Number:

When was your last massage?

Where (Spa, Private, Chain ?)

Do you see a Chiropractor?

Yes

No

If YES, how frequently?

Do you exercise?

Yes

No

If YES, how often and what kind of activity?

How does your body indicate stress?

Headaches

Muscle Tension

Sleeplessness

Other

How often do you seek a massage?

Only when I need one

Regularly

Do you often ache after a massage?

Yes

No

Do you think that's a good feeling?

Yes

No

What kind of treatment do you prefer?

Light

Medium

Deep

Please mention below any surgeries you have had, and the dates:

Do you feel that you have fully recovered?

Yes

No

If NO, please explain:

Please list any injuries or accidents that may still bother you:

Please list any prescription medications you are currently taking and for what conditions:

Please tell me why you are seeking treatment today:

I agree, the above information is accurate. I understand that massage therapy is not a substitute for medical care. I agree to alert my practitioner of any physical/emotional changes as they occur, and as they are relevant to the treatment. I understand that a missed appointment or a cancellation with less than 24 hours notice is subject to a charge I must pay.

Signature

Signature field is empty.

Date

Month

Day

Year