Intake Form

Name

First Last

Date of Appointment

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

Age

Gender

Male
Female

Marital Status

Occupation

Email

Would you like to receive coupons and discounts via your email?

Yes
No

Referred By:

Yellow Pages
Website
Friend
Facebook
Sign
Other

Whom May We Thank for Your Referral?

Have You Ever Received Massage Therapy?

Yes
No

Type of Massage Experienced?

Deep Tissue
Swedish
Other

Are You Taking Any Medications?

Are You Pregnant

Yes
No

Have You Consumed Alcohol in the Past 24 Hours?

Yes
No

Do You Have a History of the Following?

Other

Do You Have Any of the Following Today?

sunburn
severe pain
inflammation
headache
open cuts, bruises, burns
irritated skin rash
poison ivy
cold/flu

Please Indicate the Areas You Are Feeling Discomfort

What are the Goals/Expectations for this Therapy Session

Please Read the Following and Sign Below*

I Agree

I understand that this massage is not a replacement for medical care and that no diagnosis will be made.
I am responsible for paying for any appointment cancellation if less than 24 hours.

Electronic Signature

Massage Intake Form