Ascutney Mountain Massage Intake
Confidential Client Intake
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Email *
First Name *
Last Name *
Mailing Address: Street or PO Box
Zip code
Date of Birth *
Reason for visit or what would you like out of todays session?
Please state any recent injuries, surgeries , accidents or medical treatment
Please list any medications you are currently taking.
Is this your first professional massage
The above information is accurate and true to the best of my knowledge. I understand massage therapists do not diagnose disease, prescribe medication or manipulate bones. I further understand that massage therapy is not a substitute for medical attention or examination. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health. I also understand that cancelled or missed appointment without 24 hours notice (medical emergencies excluded) may be charged for the full price of the missed session.
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