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Home
Services
General Massage
Medical Massage
Exercise
Staff
Contact Us
About Us
Confidential Client Intake Form
FAQs
Policies and Procedures
Prices
Confidential Client Intake Form
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Confidential Client Intake Form
Today's Date:
*
Full Name:
*
Date Of Birth:
*
Email:
*
Phone:
*
Address
*
Occupation:
How did you hear about us?
Emergency Contact Name:
*
Emergency Contact Phone:
*
Is this your first massage?
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Yes
No
If not, approximately, when was your last one?
Prescription medications you are currently taking:
Are you currently being seen by a physician for a medical condition?
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Yes
No
If yes, please explain:
Do you exercise regularly?
Select value
Yes
No
Are you taking over-the-counter medications or vitamins?
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Yes
No
Have you recently had any surgeries or accidents?
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Yes
No
Have you had any lymph nodes removed?
Select value
Yes
No
Are there any other conditions or concerns that your therapist should know about before your treatment?
Legal Name:
*
Confirmation
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I understand that by checking this box I am signing this form and certify that the information I have provided is complete and accurate
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