Health Intake

Please fill out the following form
in order to receive massage services.

First Name

Last Name

Date of Birth

Phone

Have you been out of the US in 30 days and/or are you experiencing and COVID-19 symptoms?

Yes

Are you suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

Reason for visit

Pain Relief

Relaxation

Tension

Injury

List any allergies or hypersensitivities:

List the areas that you would like to focus on the most:

Emergency Contact Name and Number

Your Signature

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

Thanks for submitting!