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MASSAGE INTAKE FORM

CLIENT INFORMATION

CLIENT INFORMATION

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HEALTH INFORMATION

HEALTH INFORMATION

Are you taking any medications?
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Any allergies? (oils, lotions, nuts, fruits, skin, etc.)
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Are you pregnant?
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Are you currently under medical supervision or other medical interventions?
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Areas of broken skin? (e.g., rash, wounds)
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History of joint replacement surgery?
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Do you have any of the following? (check all that apply)

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Recent injuries or medical procedures in the past 2 years?
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MASSAGE INFORMATION

MASSAGE INFORMATION

Have you had a professional massage before?
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Reason for seeking massage:
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How much pressure do you prefer?
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ACKNOWLEDGMENT & RELEASE

ACKNOWLEDGMENT & RELEASE

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform the therapist of any health conditions and/ or medical changes.

CLIENT SIGNATURE

CLIENT SIGNATURE

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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