Massage Intake Form

We are excited to work with you. Please be as thorough and honest as possible when filling out your health history so that you can receive the best possible massage. 

Please contact us with any questions or when you are ready to schedule you massage!

Personal Information
Name *
Address *
Phone *
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Health History
Comfort on table *
Depending on what is going in your body, sometimes you may have various preferences while laying on the table. Please select the statement that best applies to you so that we can prepare with the appropriate comfort measures.
Please select any health conditions you have *
Typically this is towels under your shoulders due to sore breasts from breastfeeding, or side lying if laying on your stomach is too much pressure.
Additional Services
The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications or manipulate bones. I further understand that massage therapy is not a substitute for medical attention or examination. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health. Please type your name to confirm you have read this consent.