Client Intake Form

Today's Date(Required)

First Name(Required)

Last Name(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Mobile Phone(Required)

Home Phone(Required)

Work Phone

Birthdate(Required)

Occupation

Email(Required)

How did you hear about us?(Required)

Please specify(Required)

When was the approximate date of your last massage?(Required)

Why not?(Required)

Please list your common areas of pain and tension:(Required)

Please list any areas to be avoided:(Required)

Please specify(Required)

List current medications & the conditions they are treating(Required)

When were you first diagnosed with cancer?(Required)

What type of cancer?(Required)

Where was/is it located?(Required)

What treatments and/or related surgeries have you undergone? Please provide details and types of cancer treatments.(Required)

Are you currently undergoing chemotherapy? If yes, what was the date of your last treatment? Do you have a port?(Required)

Are you currently undergoing radiation? If yes, what was the date of your last treatment?(Required)

Do you have any position restrictions? Yes/No If yes, please describe.(Required)

How many weeks pregnant?(Required)

Date of COVID-19 diagnosis(Required)

Please explain any conditions that you have marked above:(Required)

Have you had any major life changes recently?

Client Agreement:

I understand that massage therapy is provided for the basic purpose of relaxation and relief of muscle tension. Massage therapy is not a substitute for medical diagnosis and/or treatment. If I experience any pain or discomfort during the session, I will alert the practitioner so modifications can be made. Because massage therapy is contraindicated under certain medical conditions, I agree to fully disclose all of my known medical conditions and medications. I agree to keep my medical profile updated and understand that there shall be no liability on the practitioner’s part should I fail to do so. I agree to consult with my physician if I have any concerns with receiving massage therapy prior to attending a massage therapy appointment. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will still be responsible for full payment of the session.

My signature also indicates my consent to the following: Failure to cancel appointments at least 24 hours in advance or failure to show up for my appointment will result in a charge of 50% of the scheduled appointment fee which will be processed on the credit card retained on file to reserve appointments. If a credit card is not available to charge, I understand that a bill will be sent to my home and agree to pay such bill.

Signature Date(Required)

Client Agreement:

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