Client Health & Preferences
NoVA Weekend Warriors | Meg Donnelly LMT, LLC | 464 Herndon Parkway #116 | Herndon, VA 20170 | 908.514.8149 | novaweekendwarriors.com

Please complete this brief Client Intake & Preferences form to the best of your knowledge before your first appointment.  The following information will be used to help plan safe and effective massage sessions. It will be kept confidential, unless a separate Release Form is signed.
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Email *
First Name *
Last Name *
Preferred Name *
Pronouns
Street Address *
City *
State *
Zip Code *
Cell Phone *
Other Phone
Date of Birth *
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/
DD
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YYYY
Emergency Contact Full Name *
Emergency Contact Relationship
Emergency Contact Phone *
Please send me electronic appointment confirmations via:
Please send me e-newsletters and special announcements via:
Referred by:
If you were referred by someone, may I thank them for referring you?
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Have you had a professional massage or mobility session before? *
If you have had a professional massage or mobility session before, how recently and what was your experience like?
Do you have any particular goals for this massage or mobility  session? *
Are there any particular areas you would like to focus on today? *
Do you have any functional or accessibility needs for your appointment?
If you have any allergies or skin sensitivities to oils or lotions, please explain:
If you are taking any medications or supplements, including prescription or over the counter, please list:
Please check any of the following that apply: *
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Please provide some brief details on any condition(s) you have checked above:
Have you ever had any lymph nodes removed, tested or in the fields of radiation? (If yes, please note where).
Is there anything else about your health history that you think would be useful for your massage therapist to know? *
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