Client Intake Form
Complete the following questions
Email *
First Name *
Last Name *
Address *
City *
State *
Zip Code *
Email *
Phone *
DOB *
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Emergency Contact *
Phone *
Occupation *
What is your primary goal for your service today?( ie: recovery, from injury, pain relief, relaxation) *
Is this your first massage? *
How many massages do you receive a year? *
What kind of pressure do you enjoy? *
What areas would you like us to focus on today? *
Do you have any allergies or skin sensitivities? (ie: oils, lotions, perfumes, latex) *
Does your stress affect you negatively in any of the following ways? *
Required
Please check all that apply to you *
Required
Please List all medications, health issues, allergies, conditions, and treatment plans either diagnosed or prescribed within the last three years. *
Draping will be used during the session- only the area being worked on will be uncovered. Clients under the age of 16 must be accompanied by a parent or guardian during the entire session.  (type name in answer box) *
I understand that the massage I receive I provided for the purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session. I will immediately inform my therapist so the pressure/strokes may be adjusted.  (type name below) *
Date *
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