Massage Intake form

First name

Last name

Phone

Email

Age

Type of massage

Relaxation massage

Deep tissue massage

If receiving a scalp massage, are you comfortable with the use of oil in your hair ?

Yes

No

Preferred massage pressure if it's relaxation massage

Light

Medium

Firm

Preferred massage pressure if it's deep tissue massage

Medium

Firm

What do you expect from a session? How do you want to feel after?

What is your favorite body area(s) to massage?

What makes you feel safe and relaxed ?

Are you currently pregnant or is there a chance you might be ?

Yes

No

Number of weeks if yes:

Any high risk factors ?

Have you had any recent injury or accident that may affect your treatment ?

Yes

No

Details if yes

Are you taking any medication(s) that may affect your treatment ?

Yes

No

Details if yes:

Do you have any allergies that might affect your treatment ?

Yes

No

Details if yes:

Would you like to include Binaural Beats or Acutonics in your session ? (at no extra cost)

No

Acutonics

Binaural Beats

Date

Day

Month

Year

Signature

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