Client Intake Form

Name *
Name
Address
Address
Phone *
Phone
Date of Birth *
Date of Birth
Do you suffer from back pain? *
please check all that apply
(feet, legs, hips, shoulders, back, etc.?)
Have you ever received? *
please check all that apply
I understand that the massage therapist is providing services within their scope of practice as defined by the American Massage Therapy Association. The therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I have notified my therapist of all known medical conditions and injuries. Should my medical conditions change in the next twelve months from date of signing this, I will notify my therapist before future sessions. If I experience pain or discomfort during the session, I will immediately inform my therapist so the treatment can be adjusted to my comfort level.
please type your full name as electronic signature
Date *
Date