Thank you for choosing [Massage Business Name]! To ensure the best possible massage experience, please complete this form.
Client Information
Emergency Contact Information
Health History
Are you currently pregnant or suspect you may be pregnant? (Yes/No)
Do you have any allergies? (Yes/No) If yes, please list:
Do you have any of the following conditions? (Please check all that apply)
Are you currently taking any medications? (Yes/No) If yes, please list:
Have you ever had a massage before? (Yes/No) If yes, how often?
What are your goals for this massage (e.g., relaxation, pain relief, improved circulation)?
Treatment Preferences
Client Signature
By signing below, I acknowledge that I have read and understood the information provided on this form. I agree to inform the massage therapist of any changes in my health condition before my massage session.
Additional Information
Thank you! We look forward to providing you with a relaxing and therapeutic massage experience.
Disclaimer: This template is for informational purposes only and should not be considered a substitute for professional medical advice. It's recommended to consult with a lawyer to ensure your massage intake form meets all legal requirements in your jurisdiction.
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