Massage Therapy Intake Form
Personal Information
First Name
Last Name
Date of Birth
Phone Number
Email Address
Address
City
State/Province
Zip/Postal Code
Emergency Contact Name
Emergency Contact Phone
Health Information
Are you currently under a physician’s care?
Yes
No
If yes, please explain
Current Medications
Allergies
Do you have any chronic conditions or injuries?
What areas would you like to focus on during your massage?
Any areas you prefer to avoid?
Previous Massage Experience
Yes
No
Comments or Additional Information
Consent
I acknowledge that the information provided is accurate and complete to the best of my knowledge.
Signature
Date