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

What is the desired day and time of your appointment? *

How did you hear about Every Bodies Massage? *

Email *

May we contact you by email regarding your appointment? *

Yes No

Telephone *

Do you speak English? *

Yes No

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

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, 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 physicial 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? *

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. *

Thank you for completing this form. Please click the SUBMIT button below.
You will be contacted soon to schedule your appointment. We look forward to seeing you!

Submit

We Would Love to Have You Visit Soon!

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