CLIENT INFORMATION

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

City

State

Zip Code

Emergency contact

Emergency Contact Phone

Relationship

HEALTH INFORMATION

Are you taking any medications

Yes

No

If yes please list

Any allergies? (oils, lotions, nuts, fruits, skin, etc.)

Yes

No

If yes please list

Are you pregnant?

Yes

No

Due Date

Are you currently under medical supervision or receiving other medical interventions?

Yes

No

If yes, please describe

HEALTH CONDITIONS

Areas of broken skin? (e.g. rash, wounds)

Yes

No

If yes, where?

History of joint replacement surgery?

Yes

No

Which joint(s)?

Recent injuries or medical procedures in the past 2 years?

Yes

No

Please describe recent injuries/procedures

Please describe any other injuries or health conditions

MASSAGE INFORMATION

Have you had professional massage before?

Yes

No

How recently?

Please describe your reason for seeking massage

How much pressure do you prefer?

Light

Medium

Deep

Please indicate any areas of discomfort

CONSENT & SIGNATURE

"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 my massage therapist of any health or medical changes."

Single choice

Yes

Date Signed

Signature

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File Upload (optional body diagram or doctor note)

A minimum deposit of $25 required to book

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