Client Intake Form Name * First Name Last Name Phone * (###) ### #### Date of Birth * MM DD YYYY Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact (Name & Phone): Phone (###) ### #### Health Information * Please check any that apply and explain if necessary: Medical Conditions (past or present): ☐ High Blood Pressure ☐ Heart Conditions ☐ Diabetes ☐ Arthritis ☐ Osteoporosis ☐ Cancer (type & status: ______________) ☐ Varicose veins Recent Surgery ( type/date ) ☐ Other Medical Conditions: ______________________ Current Medications First Name Last Name What services are you interested in? Massage Fascial How did you hear about us? Google Map Search Friend Referral Other Business Recommendations Other Please describe any specific areas: First Name Last Name Massage Preferences First Name Last Name Have you had massage before? ☐ Yes ☐ No First Name Last Name Preferred pressure: ☐ Light ☐ Medium ☐ Firm First Name Last Name Allergies (including lotions/oils): Preferred focus areas: ☐ Back ☐ Neck/Shoulders ☐ Legs ☐ Arms ☐ Feet ☐ Scalp First Name Last Name Any areas to avoid? First Name Last Name Consent & Acknowledgment First Name Last Name ☐ I understand that massage therapy is not a substitute for medical care. First Name Last Name ☐ I have disclosed all relevant health conditions to the best of my knowledge. First Name Last Name ☐ I consent to receive massage treatment. ☐ I will inform the therapist of any discomfort during the session. First Name Last Name Date: ___________ Date of Birth MM DD YYYY Text ☐ Yes ☐ No Thank you!
