Client Intake Form
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Name and Age *
Email *
Address *
Phone number *
Emergency Contact Name and Number *
Have you ever experienced a professional massage? *
Do you have any skin sensitivities or allergies? If yes, to what? *
Are you taking any medications? If yes, please list them: Include OTC and herbal supplements. *
Have you had surgery in the last 2 years? If yes, please explain. *
Do you have any pain, tingling or numbness? If yes, to where? *
Do you bruise easily? *
Have you been in an accident or suffered any injuries in the past 2 years? If yes, when? *
Are you pregnant? *
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