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New Client Health Intake Form
I need your health information prior to your first massage appointment. Please take a few minutes to fill out the information below. Thanks, Teresa Hoffer, LMT
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Email
*
Your email
Your Full Name
*
Your answer
Your Address
*
Your answer
City/State and zip code
*
Your answer
Your phone number (cell preferred)
*
Your answer
Are you male or female
*
Choose
Female
Male
Females: Are you pregnant? (*Please note that I do not give massage to women in their 1st trimester).
Choose
No.
Yes, I'm in my 2nd Trimester.
Yes, I'm in my 3rd Trimester
Birth date (month & day)
Your answer
How did you hear about me? (Who referred you?)
*
Your answer
How long ago was your last massage?
*
Your answer
Please provide the name and phone number of someone to contact in case of an emergency
*
Your answer
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