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Please fill out form and submit prior to your appointment.

MASSAGE THERAPY CLIENT INTAKE FORM

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Would you like to be added to our email list for news and exclusive offers?

MEDICAL HISTORY

Do you have or have you had any of the following conditions? Please select all that apply.
Any recent surgery, including plastic surgery?
No
Yes

MASSAGE INFORMATION

Have you had a professional massage in the past?
No
Yes
Do you have any difficulty lying on your front, back or side?
No
Yes
Do you have any allergies to oils, lotions or ointments?
No
Yes
Do you have sensitive skin?
No
Yes
What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
What pressure do you prefer?
Light
Medium
Deep

By signing below, you agree to the following: I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

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