Step 1 of 4

Client intake form

Complete the applicable questions before your massage. You can review your answers before submitting them.

Personal Information

Full name (required)PronounsDate of birthPhone numberEmailReferred byAddressEmergency contact

Have you ever had a professional massage?

Yes No

Do you have limited range of motion or difficulty getting into a seated, lying, or side-lying position on the table?

Yes No

Allergies or sensitivitiesGoals for this session or areas of focusConcerns, emotional triggers, or areas to avoid

Step 2 of 4

Share the details that may affect your massage.

Are there any current or past health concerns or injuries?

Yes No

If yes, please describePrevious surgeries, dates of surgery, and any ongoing treatmentCurrent medications

Are you currently pregnant?

Yes No

If yes, how far along?

Check all that apply

Other conditions or details about checked items

Step 3 of 4

Review and sign below. A parent or guardian must also sign for clients under 18.

Are you 18 years of age or older? (required)

Yes No

Client signature (type your full name) (required)Date signed (required)

Step 4 of 4

Check your answers and submit your intake. Once it’s received, you can print or save a copy for your records.