Name

(If your preferred name is different from your legal name, please put your preferred name in parentheses.)

First Name

Last Name

Pronouns

Birth Date

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Name and Phone Number

Primary Care Provider

Name and Phone Number

How did you hear about me?

If you were referred by a current or past client, please include their name.

TREATMENT

Goals for Treatment:

Current or Chronic Injuries:

Surgeries in the Past Two Years:

Past Treatments:

Which of these modalities have you tried?

Check all that apply.

Swedish Massage

Deep Tissue

Myofascial Release

Trigger Point Therapy

Cupping

Gua Sha ("Muscle Scraping")

Thai Massage

Reiki

Hot Stone

Occupation

Do you spend a lot of time:

sitting

standing

driving

doing repetitive motions

What kind of movement practice and/or exercise routine do you have?

MEDICAL HISTORY

Please explain:

Current Medications:

(Include dosage and frequency)

Do you have any allergies?

Are you currently pregnant or trying to conceive?

Trying to Conceive

Pregnant

If so, please list any additional details:

(Include fertility treatment side effects, concerns or complications, and due dates)

PREFERENCES

During your sessions, do you:

Like to chat

Prefer to stay quiet

Depends on the day

Do you have a preference for masking?

(KN95 and medical masks available upon request)

Practitioner and client masked

Practitioner only

No preference

Is there a specific genre or style of music you like for your sessions?

Is there anything else you want me to know?

WAIVER

+ I understand that massage is entirely therapeutic and non-sexual in nature. + I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. + If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. + I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. + I affirm that I have notified my therapist of all known medical conditions and injuries. + I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. + I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. + By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

I have read the statement above and agree to all the policies.

I agree,

Please type your full name to serve as your signature.

Today's Date

YYYY

Studio Intake Form