Massage Thereapy Intake Form

Please complete the information below so we can be sure to provide the best possible treatment

First Name*

Last Name*

Email*

Phone*

Birth Date*

Address

Country/Region*

Address*

City*

Zip / Postal code*

Emergency Contact Name*

Emergency Contact Phone*

Do you have any medical conditions?*

Yes

No

If yes, please specify

Are you currently taking any medications?*

Yes

No

If yes, please list them

Do you have any allergies?*

Yes

No

If yes, please specify

What areas would you like to focus on during your massage?

How much pressure do you prefer

Light

Medium

Heavy

Signature*

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