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Massage Intake Form

Full Name

Date of Birth

Address

Emergency Contact Name

Emergency Contact #

How did you hear about us?

Are You Taking any Medications?

If yes please mention

Are you pregnant?

If yes, how far along?

Any high risk factors?

Do you have chronic pain?

If yes please explain

have you had a professional massage before?

What pressure do you prefer?

Do you have any allergies or sensitivities?

Do any of these conditions apply to you?

If yes please explain selected conditions

Full Name

Date

By submitting the Massage Intake form, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

✨ New Specials Live! Discover limited-time spa & bathhouse deals — Check them out! 💆‍♀️ Save on Select Treatments! Exclusive offers on magnesium spa, massages & more! 🛁 Rejuvenate & Save! Balancing Spa Journeys For Less NEW LOCATION NOW Open: 57 Mathews St, Bethania

Massage Intake Form

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