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Massage Client Intake Form

Please complete this form prior to your session to help us provide you with the safest and most effective holistic treatment.

Massage Therapy Intake Form

First Name*

Last Name*

Phone Number*

Email Address*

Information about injuries or pain

Recent surgery

Yes

No

Heart or blood pressure issues

Yes

No

Are you currently pregnant?

Yes

No

Allergies or skin sensitivities

Focus areas for treatment

Areas to avoid

Preferred pressure

Light

Medium

Deep

Additional notes

I provide my consent for the massage therapy treatment.

Typed Name (Electronic Signature)*

Current Date*

Day

Month

Year

Aisha Gill

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