Client Intake Form

Personal Information

First Name *

Last Name *

Phone *

Email *

Gender *

Male or Female

Male
Female
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Date of birth

Street Address

City

Zip Code

Emergency Contact - Name *

Emergency Contact - Phone *

Health History

Please check all that apply:

High Blood Pressure

Diabetes

Heart Condition

Cancer (current or history)

Epilepsy

Varicose Veins

Recent Surgery (within 6 months)

Allergies

Pregnancy

Medications

Other health concerns

Massage Goals

Massage Goals

Relaxation

Pain Relief

Stress Relief

Sports Recovery

Brazilian Lymphatic Drainage

Post OP Care

EMS

Other

Preferences:

Area of Focus

Areas to Avoid

Preferred Pressure

Light

Medium

Firm/Deep

Cancellation Policy
•Your appointment time is reserved especially for you. We kindly ask for at least 24 hours’ notice to cancel or reschedule an appointment.
• Cancellations made less than 24 hours before the appointment may result in a 50% charge of the scheduled service.
• No-shows will be charged the full service price.

• Repeated cancellations may affect your ability to book future appointments

I agree to the Cancellation Policy