Massage Client Intake Form

"*" indicates required fields

Name*

First Last

Phone*

Address*

Street Address City State ZIP Code

Email*

Date of Birth*

Age*

Gender*

Emergency Contact*

First Last

Relation*

Phone*

Practitioner's Name*

Practitioner's Phone*

Practitioner's Address*

Street Address City State ZIP Code

Medications*

Any recent surgeries?*

(If yes, what?)

Are you pregnant or trying?*

(If yes, how far along?)

Are you nursing?*

Allergies?*

Any cuts or scratches?*

Health Conditions?*

Type of Pressure*

Light

Heavy

Deep

How often do you receive massage?*

What’s your goal for this session?*

Music preferences for session?*

Do you have sensitive skin?*

Do you exercise often?*

Areas of Pain?*

How much water do you drink daily?*

How did you hear about us?*

Name

This field is for validation purposes and should be left unchanged.