Client Massage Intake Form printable pdf download

Client Massage Intake Form

Name:

Phone #1:

Phone #2:

Date of Birth:

Email:

Address:

(city)

(state)

(zip)

Emergency Contact:

(name)

(phone #)

(relationship)

Occupation:

Employer:

Have you had therapeutic massage before?  Yes  No

Are you currently under the care of a Physician and/or Chiropractor?

Please list any injuries and/or surgeries:

Please list any allergies and/or sensitivities:

Please list all medications you are currently using:

Please check all that apply:

 Headaches

 Neck pain

 Back pain

 Leg/Knee pain

 Jaw clenching/grinding

 Seizures

 High blood pressure

 Bruise easily

 Varicose veins

 Diabetes

 Numbness/tingling: if so, where?

What is your exercise/training schedule?

Please mark areas

of pain, tension or

discomfort on the

diagram

Please note our cancellation policy: We reserve the right to charge full price for any missed appointment or appointment cancelled within 24 hours of the scheduled time.

We strive to create and maintain a professional and respectful environment. In turn, we appreciate your business and respect.

I am here to receive therapeutic massage. I understand that the Licensed Massage Therapist (LMT) will be providing therapeutic massage in accordance with the laws of the State of Texas

Health Board. I agree to hold harmless and indemnify this massage establishment and LMTs against any and all liability arising from the application of massage therapy. I declare that I have

provided the LMT with all relevant information necessary for the proper application of massage and I give my permission for such therapy. A LMT shall not engage in breast massage of

female clients without separate written consent of the client. Modest draping will be used during the session. If uncomfortable for any reason, the client may ask the LMT to cease the

massage and the LMT will end the massage session. Please be aware that deep tissue therapeutic massage can sometimes cause tenderness 24 to 48 hours after the treatment. This is a

normal reaction and may be lessened by drinking extra water. By providing your signature at the bottom of this page, you acknowledge that you understand and agree to the above

statements regarding our cancellation policy and terms of therapeutic massage.

Signature:

Date:

Client Massage Intake Form

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