New Patients, Complete the form below

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.

Massage Intake Form

Patient Information

Address
Address
City
State/Province
Zip/Postal
Country
How did you hear about us?

Emergency Contact Information

Medical Information

Are you taking any medications?
Are you currently Pregnant?
Do you suffer from Chronic Pain?
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 type of massage are you seeking?
What pressure do you prefer?
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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