Intake

Massage Therapy Intake Form

Required for new clients

URL

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

Tell us about yourself

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Emergency Contact(Required)

First Last

Emergency Contact Phone(Required)

Additional Comments or Concerns

Health Information

Current medical conditions, please describe below

Past injuries or surgeries, please describe below

Allergies (especially to oils, lotions, scents)

Medications (blood thinners, pain meds, etc.)

Skin conditions (psoriasis, eczema, infections)

Health continued, please select yes or no

Are you or is there a possibility you might be pregnant?(Required)

Yes

Kidney Disease(Required)

Yes

Cancer(Required)

Yes

Bruise easily(Required)

Yes

Suffer from anxiety(Required)

Yes

Bleeding disorder or blood clots(Required)

Yes

Autoimmune Disorder(Required)

Yes

Fibromyalgia(Required)

Yes

Diabetes(Required)

Yes

Heart condition / Hypertension(Required)

Yes

Headaches(Required)

Yes

Neuropathy(Required)

Yes

Neurological Condition / Stroke(Required)

Yes

Osteoporosis(Required)

Yes

Osteoarthritis(Required)

Yes

Seizures(Required)

Yes

Sciatica(Required)

Yes

TMJ(Required)

Yes

Varicose Veins(Required)

Yes

PTSD / CPTSD(Required)

Yes

Depression(Required)

Yes

Vertigo or Dizziness(Required)

Yes

Lifestyle and Wellness

Activity level / exercise habits(Required)

Sleep quality(Required)

Stress level(Required)

Occupation(Required)

Reason you are seeking massage

Relaxation

Specific Issue

Other

Have you ever had a massage?(Required)

Yes

How much pressure do you prefer?

Are you not interested in any of the following due to allergies, or preference?

Heated Table

Aromatherapy

Other

Reason for Other

Consent and Policies

Informed Consent for Treatment(Required)

I agree to the Informed Consent.

I understand that massage therapy is intended to promote relaxation, reduce muscle tension, and improve overall well-being. I acknowledge that massage therapists do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment or medications.

I understand that:

Massage therapy is not a substitute for medical examination or diagnosis.

It is my responsibility to communicate any discomfort, pain, or concerns during the session so the therapist can adjust the treatment accordingly.

I must inform the therapist of any health conditions, injuries, or allergies that may affect the session, and updates to my health history must be disclosed before future appointments.

If I experience any unusual symptoms after a session, I should seek guidance from a qualified healthcare provider.

I understand that draping will be used at all times and that any inappropriate behavior may result in termination of the session.

By checking the box, I give my voluntary consent to receive massage therapy and acknowledge that I have read and understood the information above.

Non-Sexual Nature of Massage(Required)

I agree to the following.

I understand that massage therapy is a strictly non-sexual therapeutic service. Any inappropriate language, behavior, or requests of a sexual nature will result in the immediate termination of the session, and full payment will still be required. The therapist reserves the right to refuse service to anyone who violates this policy.

Privacy / HIPAA Notice(Required)

I acknowledge that I have read and understand this Privacy/HIPAA Notice.

I understand that all information shared on this intake form and during my massage sessions is strictly confidential. My personal and health information will not be discussed or released to anyone without my written consent, except when required by law (such as cases involving abuse, danger to self or others, or court orders).

I understand that my therapist maintains records in compliance with HIPAA standards and takes reasonable measures to protect my privacy, including the secure storage of files and the confidential handling of all communication.

Cancellation / No-Show Policy Acknowledgment(Required)

I acknowledge that I have read, understand, and agree to the below Cancellation/No-Show Policy.

I understand that my appointment time is reserved especially for me. If I need to cancel or reschedule, I agree to provide at least 48 hours’ notice.

Cancellations made with less than 48 hours’ notice may be subject to a cancellation fee (up to the full session cost).

Missed appointments when therapist has already departed for destination will be charged the full session fee.

Repeated late cancellations or no-shows may result in the refusal of future appointments.

Exceptions may be made for true emergencies at the discretion of the therapist. I agree to communicate as soon as reasonably possible if an emergency arises.

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice