Client Intake Form

Personal Information

Full Name *

Email *

Date of Birth

Emergency Contact

Contact Name

Contact Phone

Medical History

Do you have any of the following conditions? (Check all that apply)

Allergies (including oils, lotions, or scents)

Current Medications

I have received professional massage therapy before

Massage Preferences

Consent & Signature

I understand that massage therapy is provided for stress reduction, relief from muscular tension, and improvement of circulation and energy flow. I understand that massage therapists do not diagnose illness, disease, or any other physical or mental disorder. I have stated all my known medical conditions and will keep my therapist updated on any changes. I understand that there may be additional risks based on my physical condition. I agree that I am responsible for informing the therapist if I experience any pain or discomfort during the session so adjustments can be made.

I have read and agree to the above statements *

Digital Signature (Type your full name) *