Client Intake Form

Client Intake Form

  • MM slash DD slash YYYY
  • General Health

    5 = Highest, 1 = Lowest
  • Massage Therapy

  • Health History

  • Skin Care

  • By submitting, I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it superseded any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. The treatments I receive here are voluntary and I release this institution and individual therapist from any and all liability and assume full responsibility thereof. For minors under the age of 18, parent or guardian signature constitutes consent.