New Client Intake Form
This form is required for all new clients. Please take a few moments to answer the questionnaire so that I may be better suited to provide you with an effective therapeutic massage.
This online form is securely hosted. I will not release personal information to any other party.
The final section of this form has been included per the Booking/Cancellation policy (please see:
Email address *
Name *
Your answer
Phone number *
Your answer
Mailing Address
Your answer
Referred by
Your answer
Emergency Contact
Your answer
Your answer
Is this massage/bodywork medically necessary? (Is it part of a treatment plan for an injury or condition?)
Have you ever received professional massage/bodywork?
If "Yes," how recently?
Your answer
What is your preferred pressure.
Current complaints:
Health history: 1/2
Please indicate whether you have or have had in the past any of the following:
Muscle or joint pain/stiffness
Numbness or tingling
Bruise easily
Sensitive to touch/pressure
Stroke, heart attack
High/Low blood pressure
Varicose veins
Shortness of breath, asthma
Neurological (e.g. MS, Parkinson's chronic pain, etc.)
Epilepsy, seizures
Headaches, migrains
Dizziness, ringing in ears
Digestive conditions
Gas, bloating, constipation
Kidney disease
Osteoporosis, degenerative disc disease
Endocrine/thyroid conditions
Depression, anxiety
Memory loss
Health history: 2/2
Describe any of the above conditions that you may have or have had, including treatments you have undergone.
Your answer
Medication List
Some medications can be contraindicated for massage.
Your answer
Your answer
Cancellation Policy *
I understand that unanticipated events happen occasionally in everyone’s life. In my desire to be effective and fair to all clients, the following policies are honored: 24 hour advance notice is required when cancelling an appointment. This allows the opportunity for someone else to schedule an appointment. If you are unable to give 24 hours advance notice you will be charged 50% of the full amount of your appointment. This amount will be charged to the credit card on file. If you do not leave a credit card on file, I will require a cash or VenMo non-refundable 50% deposit to schedule your next appointment. No-shows: Anyone who either forgets or consciously chooses to forego their appointment for whatever reason will be considered a “no-show," and will be charged the full amount for the missed appointment and required to provide a 50% cash or VenMo deposit when attempting to schedule again. If this becomes a habit, you will no longer be booked. Late Arrivals: If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the full session. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time.Thank you for your cooperation!
Consent for Treatment *
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. The following must be answered "yes" to consent for bodywork.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms