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Massage Therapy Intake Form

This document collects personal and medical information from a new client through an intake form. It requests the client's name, contact details, date of birth, occupation, emergency contact, how they heard about the business, and preferences for appointment confirmations. Medical details include current pregnancy status, existing conditions, surgeries, medications, and allergies. A body diagram is included to mark any areas of pain or discomfort. By signing, the client agrees they have provided accurate information and understand massage is not a substitute for medical care. They also release the business from any liability for complications during treatment.

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Carla Lebron
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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145 views1 page

Massage Therapy Intake Form

This document collects personal and medical information from a new client through an intake form. It requests the client's name, contact details, date of birth, occupation, emergency contact, how they heard about the business, and preferences for appointment confirmations. Medical details include current pregnancy status, existing conditions, surgeries, medications, and allergies. A body diagram is included to mark any areas of pain or discomfort. By signing, the client agrees they have provided accurate information and understand massage is not a substitute for medical care. They also release the business from any liability for complications during treatment.

Uploaded by

Carla Lebron
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Client Intake Form

NAME:_____________________________________________ PREFERRED NAME:________________________________

EMAIL:______________________________________________________________________________________________
MOBILE PHONE:______________________________________________________________________________________
DATE OF BIRTH:________________________________OCCUPATION:______________________________________
HOW DID YOU HEAR ABOUT US? ______________________________________________________________________
HOW WOULD YOU LIKE TO RECEIVE APPOINTMENT CONFIRMATIONS? EMAILS TEXTS BOTH
WOULD YOU LIKE TO RECEIVE EMAILS REGARDING MONTHLY SPECIALS? YES NO

EMERGENCY CONTACT:_______________________________________________________________________________
PHONE:___________________________________RELATIONSHIP:____________________________________________
PREFERRED THERAPIST/GENDER:______________________________________________________________________

ARE YOU CURRENTLY PREGNANT? ______________DOCTOR ______________________________________________


MEDICAL CONDITIONS/SURGERY/MEDICATIONS/ALLERGIES :_____________________________________________
____________________________________________________________________________________________________

____________________________________________________________________________________________________

PLEASE CIRCLE ON THE DIAGRAM ANY


AREAS WHERE YOU ARE FEELING PAIN,
TENSION, DISCOMFORT, OR PRIOR
SURGERY.
OTHER COMMENTS:
________________________________________
________________________________________
________________________________________

I have completed this intake and consent form to the best of my knowledge. By signing below, I hereby certify that the
information provided is correct. I understand that massage therapy and bodywork is a health aid and does not
substitute for medical care. I will inform the center and the therapist of any special needs, medical conditions, or
changes in my health. Any and all information exchanged during treatment is confidential and is only used to provide
the best treatment possible. If I am having or develop any complications during my service, I will promptly discuss this
with my therapist. I hereby voluntarily release Renew Wellness Center, Central Florida Massage Clinics and the
independent contractor for service from any liability or complications that may occur. By signing below, I agree that I
have read the information above and have decided to receive services at my own risk.  

CLIENT SIGNATURE______________________________________DATE__________________________________

NAME:_____________________________________________PREFERRED NAME:________________________________ EMAIL:_____________________

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