Client Intake Form - Get as DOC

							                                         Client Intake Form

Event:         ____________________________________________________________


For our records, please complete the information below and give it to your massage practitioner:

Name:          ____________________________________________________________

Address:       ____________________________________________________________

Town:          __________________________ Phone: __________________________

1.             Do you currently have any medical conditions         Yes     No
               which you are seeing a physician?

2.             If yes, please let therapist know as it may be affected by today’s massage.




3.             Have you had a recent injury or illness?             Yes     No

4.             If yes, please explain:



5.             Please list the areas for which you would like
               specific attention:


This therapist or massage establishment is not responsible for the aggravation of conditions which were
present but not disclosed to the practitioner at the time of massage and which may be affected by
massage.

Client Signature:     ____________________________________________________________

Date:          ____________________________________________________________


Therapist Signature _______________________________________________________
                              (Please write legibly or print)