This intake form is designed to help us understand your unique needs and preferences, ensuring a personalised and effective massage therapy experience.

By providing detailed information about your health history, current conditions, and specific areas of discomfort or concern, you enable us to tailor our approach to best suit you.

Your responses will be kept confidential and used solely to enhance the quality of your care.

Thank you for taking the time to fill out this form. We look forward to providing you with exceptional service.

Client Intake Form

Client Intake Form

Gender (optional)
Address (optional)
Address (optional)
Line 1
Line 2
Medical History (optional)
Do you or have you had any of the following conditions? If yes, please select them:
Any recent surgery, including plastic surgery?
Have you had a professional massage before?
Do you have any difficulty lying on your front, back or side?
Do you have any allergies to oils, lotions or ointments?
Do you have sensitive skin?
What type of massage are you seeking?
What pressure do you prefer?
Any specific areas you would like your therapist to concentrate on?

Scope of Practice

Massage therapy is a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, with the intention of positively affecting the health and well-being of the client.

Massage Therapists do not diagnose or prescribe for medical conditions nor are they allowed to provide treatment for a specific condition without a doctor's supervision. The massage therapist is required to refer you for diagnosis and to follow recommendations of your physician.

The massage therapist are happy to adjust pressure, temperature, music volume, work longer on an area or move on if you request it.

Medical Conditions

It is the responsibility of the client to keep the massage therapist informed of any medical treatment currently being taken, and to provide written permission from the physician, chiropractor, physical
therapist, etc., that the massage may be continued.

The client must also keep the massage therapist informed of any changes in health conditions.
I confirm, that
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I confirm, that
My signature acknowledges that I have read and agree to receive the massage therapy and that I will adhere to all of the previously mentioned statements that I have confirmed.