Massage Intake Form
Personal Information
Name ________________________________________ Phone (day) _____________________ (evening) _____________________
Address _____________________________________ City/State/Zip _________________________________ DOB ___________
Occupation _____________________________________________ Employer ___________________________________________
Email _______________________________________________ Primary Physician _______________________________________
Emergency Contact ____________________________________ Relationship __________________ Phone __________________
How did you hear about us? ____________________________________________________________________________________
Medical Information Massage Information
Are you taking any medications? ☐ yes ☐ no Have you had a professional massage before? ☐ yes ☐ no
If yes, please list name and use: _____________________ What type of massage are you seeking?
_______________________________________________ ☐ Relaxation ☐ Therapeutic/Deep Tissue
Are you currently pregnant? ☐ yes ☐ no Other ___________________________________________
If yes, how far along? ______________________________ What pressure do you prefer?
Any high risk factors? ______________________________ ☐ Light ☐ Medium ☐ Deep
Do you suffer from chronic pain? ☐ yes ☐ no Do you have any allergies or sensitivities? ☐ yes ☐ no
If yes, please explain ______________________________ Please explain ________________________________
What makes it better? _____________________________ Are there any areas (feet, face, abdomen, etc.) you do not
_______________________________________________ want massaged? ☐ yes ☐ no
Please explain _______________________________
What makes it worse? ____________________________
What are your goals for this treatment session?
_______________________________________________
_____________________________________________
Have you had any orthopedic injuries? ☐ yes ☐ no
Please circle any areas of discomfort
If yes, please list: ________________________________
Please indicate any of the following that apply to you.
☐ Cancer ☐ Fibromyalgia
☐ Headaches/Migraines ☐ Stroke
☐ Arthritis ☐ Heart Attack
☐ Diabetes ☐ Kidney Dysfunction
☐ Joint Replacement(s) ☐ Blood Clots
☐ High/Low Blood Pressure ☐ Numbness
☐ Neuropathy ☐Sprains or Strains
By signing below, you agree to the following.
Explain any conditions you have marked above: I have completed this form to the best of my ability and knowledge
and agree to inform my therapist if any of the above information
________________________________________________
changes at any time.
________________________________________________
________________________________________________ Client Signature __________________________ Date __________
________________________________________________ Therapist Signature _______________________ Date __________
INTENDED HEALTH BENEFITS:
MASSAGE THERAPY SERVICES
Your Name:
List the specific health benefits you intend to achieve through massage therapy:
Now describe the level of health you’d like to be experiencing one year from today:
Are there any mental/emotional changes you need to make to achieve that goal?
Signature Date
Policy Notification
We appreciate that you have chosen us for your massage and bodywork needs. To provide the best service possible
to our clients, we have implemented the following policies.
Cancellation Policy
We respectfully ask that you provide us with a 24-hour notice of any schedule changes or cancellation requests.
Please understand that when you cancel or miss your appointment without providing a 24-hour notice, we are often
unable to fill that appointment time. This means that our other clients miss the chance to receive services they
need. For this reason, you will be charged 50% of the service fee for the first missed appointment and 100% of the
service fee for each appointment after that. We also reserve the right to require a credit card number to be given to
book future appointments so that appropriate fees may be charged if a late cancellation does occur. We understand
that emergencies can arise and illnesses do occur. If you have a fever, a known infection, or have experienced
vomiting or diarrhea within 24-hours prior to your appointment time, we request that you reschedule your
appointment. Inclement weather may also result in the need for late cancellation. We will do our best to give
advanced notice if we are closing or need to cancel due to bad weather and we ask that you do the same. Please do
not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement
weather will generally not result in any missed session charges, but this is determined on a case-by-case basis.
Late Arrival Policy
We request that you arrive 5-10 minutes prior to your appointment time to fill out any required paperwork as well
as answer any intake questions your therapist may have. We understand that issues can arise that may cause you to
be late for your appointment. However, we ask that you call/text to inform us if this ever occurs so we can do our
best to accommodate you. Appointment times are reserved for each client, so oftentimes, we cannot exceed that
reserved time without making the next client late. For this reason, arriving after your appointment time may result
in loss of time from your session so that your session ends at the scheduled time. Full service fees will be charged
even when sessions are shortened due to the late arrival. In return, we will do our best to be on time, and if we are
unable to do so, we will add time to your session to make up for our late arrival or adjust the service charge
accordingly.
Inappropriate Behavior Policy
Massage Therapy and Bodywork is for relaxation and therapeutic purposes only. There is absolutely no sexual
component to massage and bodywork whatsoever. Any insinuation, joke, gesture, conversation, or request
otherwise will result in immediate termination of your session and a refusal of any and all services in the future. You
will be charged the full-service fee regardless of the length of your session. Depending on the behavior exhibited, we
may also file a report with the local authorities, if necessary. Treat your therapist with respect and dignity and you
will be treated the same in return.
I, the undersigned person, do agree and understand that the Massage Therapist is and only claims to be a Massage Therapist and
provides the services of massage therapy only. I understand and agree that the Massage Therapist does not diagnose, prescribe or
claim to treat any condition or ailment. I have informed the Therapist that I am free of any medical conditions such as blood clots,
cancer, tumors, recent injuries or surgeries, phlebitis, spinal injury, or any other significant medical condition. I also agree not to
hold the Massage Therapist liable for any adverse reaction I may experience from this massage.
By signing below, you agree to abide by these policies.
_______________________________________________ ________________________
Client Signature Date
