MASSAGE INTAKE FORM

Before your visit, we would like to know more about you and plan your treatment accordingly. Please fill out the form below prior to your appointment.

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Patient Information

Address
How did you hear about us?

Medical Information

Are You Taking Any Medications?
Do You Suffer From Chronic Pain?
Are You Currently Pregnant?
Have You Had Any Orthopedic Injuries?
Please Indicate If You Have Any Of The Following Conditions:

Massage Information

Have you had a professional Massage before?
What pressure do you prefer?
What type of massage are you seeking?
Do you have any allergies or sensitivities?

By Submitting This Form:

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 should change at any time.

Please check here before submitting.
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