New Massage Client Intake Form

Personal Information

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Emergency Contact Name

Emergency Contact Phone Number

Physician's Name

Physicians Phone Number

Massage Preferences

Have you had a professional massage before?

Yes

No

If yes, at what frequency?

What are your goals for this treatment?

Areas you don't want massaged?

Current Health

Reason for initial visit:

Do you exercise regularly and/or participate in any sports?

Yes

No

If yes, what kind?

Do you perform any repetitive movement in your work, sports or hobbies?

Yes

No

If yes, please describe:

Do you sit for long hours at a workstation, computer, or driving?

Yes

No

If yes, please describe:

Do you experience stress at work or in your personal life?

Yes

No

If yes, please describe:

Are you experiencing tension, stiffness, discomfort or pain?

Yes

No

If yes, please describe:

Have you recently had an injury, surgery, or areas of inflammation?

Yes

No

If yes, please describe:

Do you have sensitive skin?

Yes

No

Do you have any allergies to oils, lotions or fragrances?

Yes

No

If yes, please describe:

List any medications you are currently taking:

List any known allergies:

Do you have any of the following conditions?

Check all that apply

If you have respiratory allergies, please specify:

Reproductive

Pregnant

Prostate Issues

Ovarian /Menstrual Problems

PCOS /Endometriosis

If pregnant, please state how many weeks:

If you have skin allergies, please specify:

Other, please specify:

If there are any other conditions, we need to be made aware of, please specify:

Any additional information or notes you have about the boxes you checked.

Consent and Liability Waiver

I authorize Erstwhile Studios, LLC. and my massage therapist to perform the treatment of necessary procedure for my child. (If applicable.)

I authorize the use of lotion, oil, and ointments to my body.

I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.

I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.

I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.

I release Erstwhile Studios, LLC and my massage therapist from any responsibility in case of an accident, illness, or injury.

I acknowledge that all information I provided in this form is true and accurate.

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Signature

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