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Massage Client Intake Form
The information you provide in this form will be kept private and secure and will not be shared or sold.
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Email *
Name (Last, First) *
Date of Birth (Month/Day/Year): *
Street Address *
City, State, Zip-code *
Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number *
Do you have allergies? *
If 'YES' to allergies, please list/explain:
Please list your current medications:
Have you ever had a massage? (select all that apply) *
Required
Are you in pain today? *
If you are in pain today, please explain:
What is your preferred depth of pressure during your massage? *
Required
Please check any current or past medical conditions: *
Required
I understand that massage is not a substitute for care by a physician. I further understand that this information is provided to assist the Massage Therapist in providing appropriate care. In consideration for private massage, I release Love Life Massage and Wellness, LLC and their employees of all liabilities, claims, damages, cost, and expenses. Please type your full name below if you agree to these terms. *
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