Full Name *

Pronouns You Prefer (they/them; she/her, he/him...)

Phone *

Email *

Address *

Date of birth *

Type of Work You Do

Emergency Contact Name and Phone Number *

Have You Ever Received Massage Before?

Yes

If so, how often?

What are your goals with massage therapy?

What areas would you like to prioritize for your massage?

Are you currently seeing a medical practitioner? *

Current medications? *

What activities do you do regularly for relaxation, well-being? How often?

Please list past surgeries and approximate dates

Have you experienced any accidents or injuries? Please give approximate dates

Please list any conditions that you currently have.

Is there anything else you would like me to know before your massage?

I understand that massage therapists do not diagnose illness, disease or physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals, or perform spinal manipulations or skeletal adjustments. Because massage/bodywork should not be performed under certain conditions, I affirm that I have stated all my known medical conditions, or answered all questions asked of me honestly. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that it is recommended I see a primary health care provider for that service. If I experience any pain or discomfort during the session, I will immediately inform the massage therapist so that the service may be adjusted to my level of comfort or discontinued. If I am unable to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case I will call ASAP to reschedule my appointment. If I miss a scheduled appointment without giving 24-hour notice, I agree to pay the missed appointment fee that applies. *

I agree to receive massage therapy and bodywork.