The Boston Bodyworker Intake Form
Please complete the following information prior to your initial visit with us
Sign in to Google to save your progress. Learn more
Email *
Name *
Dat of Birth *
Address *
Mobile Phone number *
Your preferred pronoun
Clear selection
Height *
Weight *
How did you hear about us? *
Are you currently training for an event? If Yes, please explain.
What is your primary goal for todays visit?
What is your primary complaint? *
Are you currently under the care of a medical doctor for your visit today? *

Please read carefully and check the appropriate box:

Recommendation may be given by the Therapist with reference to future treatments, activities, occupational and sleep mechanics. The Therapist neither diagnoses illnesses, disease or any other physical or mental disorder, nor performs any spinal manipulations. At times, one may feel some post- therapy tenderness due to lengthening and compression of connective tissue.

I understand that the massage services provided by this licensed Massage Therapist are provided pursuant to and in accordance to the laws of the state of Massachusetts governing massage therapy and that a full and complete medical disclosure is essential in providing such therapy. I agree to hold harmless, release and indemnify this massage establishment against any and all liability arising from the application of massage therapy. By signing this release form, I hereby declare that I have provided the Massage Therapist with all relevant information necessary for the proper application of massage therapy and I expressly give my permission for this Massage Therapist to provide such therapy.



Please read carefully and check the appropriate box:

 I understand the Boston Bodyworker 24 Hour Cancellation Policy, as follows:

First: “Late Cancel” or “No Show” – No Fee. Second: “Late Cancel” or “No Show” – 25% fee of the original price of the missed appointment.

Third: “Late Cancel” or “No Show” – 50% fee of the original price of the missed appointment.

Any appointment following these occasions will be subject to a charge of the full fee of the missed appointment.

Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy