Massage intake · About you

About you

So we can reach you and keep your notes in one place.

Your full name *

Phone *

Email

Date of birth *

Address

In case of emergency

Someone we could call if we ever needed to.

Contact name

Relationship

Their phone

How did you hear about us?

Health history

Some conditions change how your therapist works, or mean they should not work at all. None of this is required, but the more we know the safer your session is.

If pregnant, how many weeks?

Medications you take

Recent injuries, surgeries, or accidents

Anything else your therapist should know

Your massage

How you like to be worked on. You can change any of this during the session.

How much pressure do you like?

Light Medium Deep Not sure yet

Have you had a professional massage before? *

Yes No

Anywhere we should avoid?

Any oil, lotion, or scent allergies?

Sore spots

Tap where you want me to focus. Left and right are yours, not the picture's.

Front

Back

Consent

The last step. Please read this, then sign below.

Consent to treatment

Please read each point before you agree.

I have read the above and I consent to receive massage therapy.* The information I have given is accurate as far as I know.* You may send me appointment reminders and occasional offers. (Optional, and you can stop this any time.)

Your signature *

Sign with your finger or your mouse.

Sign here

Type your full name *

Date

Tell us how to take good care of you.