Massage intake · About you

About you

So we can reach you and keep your notes in one place.

Your full name *

Phone, daytime *

Phone, evening optional

Email optional

Date of birth optional

Address optional

City, state & ZIP optional

Occupation optional

Employer optional

Primary physician optional

In case of emergency

Someone we could call if we ever needed to.

Contact name optional

Relationship optional

Their phone optional

How did you hear about us? optional

Health history

Some conditions change how your therapist works, or mean they should not work at all. None of this is required, but the more we know the safer your session is.

If pregnant, how many weeks? optional

Medications you take optional

Recent injuries, surgeries, or accidents optional

Anything else your therapist should know optional

Your massage

How you like to be worked on. You can change any of this during the session.

How much pressure do you like? optional

Have you had a professional massage before? optional

This is my first A few times Regularly

Where should we focus? optional

Anywhere we should avoid? optional

Any oil, lotion, or scent allergies? optional

Room preference optional

What would you like from this session? optional

Sore spots

Tap anywhere that aches, feels tight, or you want looked at. Left and right are yours, not the picture's.

Front

Back

Tell us about those spots optional

Consent

The last step. Please read this, then sign below.

Consent to treatment

Please read each point before you agree.

I have read the above and I consent to receive massage therapy.* The information I have given is accurate as far as I know.* You may send me appointment reminders and occasional offers. (Optional, and you can stop this any time.)

Your signature *

Sign with your finger or your mouse.

Sign here

Type your full name *

Date

Tell us how to take good care of you.