Massage Intake Form

Personal Information

First name

Last name

Email

Phone

Address

Have you had a professional massage before?

Yes

No

If yes, please list name and use

Are you currently pregnant?

Yes

No

Are you suffering from chronic pain?

Yes

No

If yes, please explain

Please provide details of your conditions.

By signing below, you agree to the following.

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 changes at any time.

Signature

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