Intake form

Name

First

Last

Email

Reason for visit

How would you rate your general health?

Describe injuries, concerns, or issues to address + causes and dates of occurrences that I the therapist need to know of ?

Have you the client any Medical issues that I the therapist needs to be made aware of ?

Have you ever had a professional massage?

Yes
No

Have you any allergies that I the therapist needs to be made aware of before the treatment ?

Yes
No

to answered to

Are you willing for the therapist to take videos of the treatment for business purposes and social media ?

Yes
No

You have read ands agree to the information on the page linked below

Yes
No

Please read *opens in new browser tab

All of the information above I have given is correct and I have listed any contradictions to the therapist.

yes

test

I have been given and or are aware that the opportunity to ask questions about massage therapy, and my questions have or will been answered to my satisfaction.

Yes
No

Client Intake Form