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New Client

Client Intake Form.
Therapeutic Massage.

Please complete this form before your first session. All information is kept confidential and used only to provide you with the best possible care.

Personal Information

Emergency Contact

Massage Information

Click the body zones that apply to you.

Click or tap on any area to mark it as a problem or focus area. Selected areas will highlight in gold. You can select multiple areas on both the front and back views.

Front

Back

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Health Information

Health Conditions

Please check any conditions that apply to you.

Massage Guidelines & Expectations

Please read all guidelines carefully before submitting.

  1. 1.Massage sessions will begin and end at the scheduled time. Sessions that begin late due to the client's late arrival will end at the scheduled time and the client will be billed for the full time.
  2. 2.All clients will be treated with respect and dignity. Personal and professional boundaries will be respected at all times.
  3. 3.Clients must provide an accurate health history and agree to inform their therapist of any updates or changes to their health/medical condition.
  4. 4.Any client with a contagious condition including common cold, influenza, stomach flu, coronavirus, meningitis, shingles, or contagious skin conditions must not schedule an appointment, but call to inform the therapist before scheduled appointment time. Clients may reschedule after the condition has resolved.
  5. 5.Clients with signs or symptoms of an active systemic or localized infection (e.g. fever, sore throat, swelling, etc.) at the time of a scheduled massage are asked to notify their therapist and reschedule.
  6. 6.Massage therapists only provide therapeutic massage and modalities within the scope of practice for this licensed profession. Clients with acute injuries or conditions outside the scope of massage should consult their doctor.
  7. 7.All clients will be appropriately draped with a sheet at all times during the massage session. Only the area(s) currently being worked will be exposed. The genital area is never exposed or massaged.
  8. 8.Client privacy and confidentiality will be maintained at all times.
  9. 9.Any client who arrives under the influence of drugs or alcohol will be asked to leave.
  10. 10.Please refrain from smoking at least 1 hour prior to your appointment and during the massage session, or ventilate the area beforehand. A reasonably odor-neutral environment is appreciated for the comfort of both client and therapist.
  11. 11.Clients are expected to be clean and have showered prior to receiving massage on the same day.
  12. 12.All clients are provided with a competent and professional massage that focuses on the needs of each individual client.
  13. 13.Harassment of any kind is not tolerated and the session will be terminated immediately if this occurs, or if the practitioner's safety is compromised in any way.
  14. 14.Clients are asked to avoid eating a heavy meal during the two hours prior to receiving massage.
  15. 15.Appointments are confirmed between one to two days prior to the scheduled appointment.

Consent & Agreement

By submitting this form, I acknowledge that I am aware of the benefits and risks of massage therapy, that I have read and agree to the massage guidelines and expectations listed above, and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes prior to future sessions.

Your information is kept strictly confidential and used only to provide you with professional massage therapy care.