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Initial Massage Therapy Form
This form was developed to ensure all patrons are fully aware of rights, benefits, risks as well as letting your therapist know about the treatment you would like, your focus and most important your health history.
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Today's Date *
Full first and last name *
Birthday *
MM
/
DD
/
YYYY
Address (street, city, postal code) *
Email *
Primary Contact Number *
Home Number
Work Number
Occupation *
What is your preferred method of communication? *
Required
Whom should we thank for referring you to us? *
Required
Have you received massage therapy before? *
Who is your primary care physician? Address? *
(If you do not have a physician please enter N/A)
Current Medication? *
If YES type what medication and what it treats in the field marked "Other"
Required
Are you receiving treatment from another healthcare professional? *
Required
If you answered YES to the last question, what is the treatment for?
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