1. Client Intake Form

    An user account will be created on completion of this form. You will then be able to access a history of your sessions. A copy of this form will be emailed to you.
  2. Personal Information

  3. Name
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  4. Email(*)
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  5. Phone
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  6. Address
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  7. City
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  8. State
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  9. Zip
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  10. Date of Birth
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  11. Occupation
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  12. Emergency Contact
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  13. Emergency Contact Phone
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  14. Affiliations







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  15. Medical History

  16. 1. Have you had a professional massage before?
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  17. 2. Do you have any difficulty lying on your front, back or side?
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  18. 3. Do you have sensitive skin or any allergies to oils, lotions, or ointments?
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  19. 4. Do you perform any repetitive movement in your work, sports, or hobby?
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  20. Please Describe
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  21. 5. Is there a particular area of your body where you are experiencing tension, stiffness, pain, or other discomfort?
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  22. Please Describe
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  23. 6. Do you see a chiropractor?
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  24. 7. Are you currently taking any medication?
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  25. Please Describe
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  26. 8. Is there anything else about your health history that you think the massage therapist should know to plan a safe effective massage session for you?
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  27. Please Describe
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  28. Please check any condition listed below that applies to you:






























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  29. How Many Months Pregnant
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  30. Agreement

  31. Agreement(*)
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  32. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medial specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, 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.
  33. Captcha
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