Rincon Massage Therapy & Holistic Health 
General Intake Form.  
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Email *
First & Last Name *
Mobile: *
Email: *
To ensure I arrive on time, may I have the exact location for the session? A Google Maps pin & the name of your residence/building.  *
Known Allergies *
Any contraindications to receiving massage I need to be aware of?  *
How did you hear about my services *

Do you have any physical limitations I should be aware of? 

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Describe relevant injuries, concerns, or issues to address.

 *

Check any of the following contraindications or considerations to receiving massage:

 *
Required

List any medications that you are taking for the contraindications listed above.

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Date of most recent professional massage?  *
How often do you like to receive massage? *
Check your preferred type of massage: *
Emergency Contact Name & Phone Number *
Emergency Contact Name & Phone Number *
I hereby consent to a massage treatment including but not limited to Gua Sha, Moxibustion, and Cupping. These treatments may lead to tenderness and visible marks. I will ask my practitioner for further details about these if required.

I understand and accept the use of Rincon Massage Therapy & Holistic Health with holding information present on my file. 

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