New Client Intake Form

Every Bodies Massage

New Client Intake Form for Appointment Requests

Background and Contact Information:

* Indicates required field

Name: First, Last *

First

Last

How did you hear about Every Bodies Massage? *

Do you speak English? *

Yes No

Email *

May we contact you by email regarding your appointment? *

Yes No

Telephone *

Is this a cell phone or landline? *

Cell Phone Landline Phone

May we contact you by telephone or text message regarding your appointment? *

Yes No

Duration of Massage *

90 Minutes 60 Minutes 30 Minute

Do you have a preference of days or times for your appointment? For example, Tuesday mornings, weekends, etc. Please note, Every Bodies is closed on Mondays *

Prior Massage Experience:

Have you had a massage in the past? *

Yes No

When was your last massage? *

What kind of massage was it (deep tissue, relaxation, prenatal, etc.)? *

Medical History:

Why are you seeking a massage at this time (relaxation, pain management, specific injury or illness)? *

Are you currently taking any medications (prescription or OTC)? *

Yes No

Are you currently being treated by a physician or other medical professional? *

Yes No

If yes, please list medications and what they are for. *

If yes, please explain: *

Have you had any recent accidents, surgeries and/or traumas? *

Yes No

If yes, please describe. *

Are you female with a possibility that you are pregnant or are you pregnant? *

Yes No

Do you have any special needs that we should be aware of (wheelchair, walker, difficulty climbing stairs, etc.) *

Yes No

Do you have any allergies or sensitivities? *

Yes No

If yes, please describe. *

If yes, please explain. *

DO YOU HAVE A GIFT CERTIFICATE? *

Yes No

IF YES, PLEASE PROVIDE THE CERTIFICATE NUMBER. *

Thank you for completing this form. Please click the SUBMIT button below.
You will be contacted soon to schedule your appointment. If you do not hear a response within 24 hours,
please call or text to 508-603-9779. We look forward to seeing you!

Submit

35 Main St, Suite 6, Hopkinton, MA 01748

We Would Love to Have You Visit Soon!

Hours
By Appointment

Telephone
508-603-9779

Email
[email protected]

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