MASSAGE INTAKE FORM Name (Legal & Preferred) Preferred Pronouns E-mail / Phone / Address Emergency Contact Details * Have you received massage therapy or other types of bodywork before? Is there anything in particular that has resonated with your body? Are there any areas of your body or intentions you'd like to prioritize? Are there any scents or essential oils that you particularly enjoy? Do you have any specific needs in terms of accessibility, allergies, religious or cultural requirements or boundaries? If you're willing to disclose, do you have any triggers I should be aware of prior to your session? We can check in on this during your intake. Are you pregnant? Or have you given birth? Please list any recent or significant surgeries. Please list any past and current medical conditions. UNDERSTANDING It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent. I understand that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that there is a 24-hour cancellation policy and after that a $50 fee will be charged if canceled after that time. Date MM DD YYYY Thank you!
