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Client History/Intake Form

Please complete or print out and bring to your appointment (link Below)

First and Last Name*

Mailling Address*

Email Address*

Cell Phone*

Home Phone

Date of Birth*

Sex*

Who may we call in case of an emergency?*

Emergency Contact Phone Number*

Please list any medical concerns; anything you are seeing a physician for presently or within the last 2-3 years..*

Your Body: Please check all that apply

Your Massage Experience : Select all that your desire.*

Covid History : Select all that apply*

I have been tested for covid in the past 2 weeks

I tested POSITIVE for covid

I tested NEGATIVE for covid

I have been caring for someone who is ill within the past 2 weeks.

I currently have at least one of the following symptoms: fever, chills, cough, sore throat, diarrhea, shortness of breath, rash/skin lesion, or loss of taste/smell.

Does NOT apply to me

Consent to Massage* - your name

Thanks for submitting!

CLIENT HISTORY (INTAKE) FORM (printable)

Therapeutic Room(Waiver) FORM (printable)

POLICIES AND PROCEDURES (printable)

Physician's Consent Form (Printable)

WELLNESS PACKAGE AGREEMENT FORM (Printable)

PRENATAL MASSAGE INTAKE FORM (Printable)

MOMMY 2 BE PACKAGE FORMS (Printable)