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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*

CLIENT HISTORY (INTAKE) 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)