Massage Intake Form

Information you will need

• SPA/MASSAGE THERAPIST ONLY: What's the spa or massage therapist's name?
• CLIENT ONLY: What's your name?
• What's your street address?
• What's your city?
• What's your state?
• What’s your email address?
• What's your phone number?
• What's your emergency contact's phone number?
• What's the name of the person who referred you? (optional)
• What medications are you taking?
• Do you take any medications?
• Do you have any allergies?
• What are your allergies?
• Are you pregnant?
• Are you receiving medical supervision or interventions?
• What type of medical supervison or interventions are you currently undergoing?
• Do you have any areas of broken skin?
• Have you had joint replacement surgery?
• Do you have any areas of swelling?
• Do you have an autoimmune disorder?
• Do you have back or neck problems?
• Do you have bleeding disorders?
• Do you have any blood clots?
• Do you bruise easily?

…and 44 more fields in the PDF.

Completed by the client.

The form includes 1 signature line, a notary acknowledgment.