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    Massage Intake

    Uploaded by

    Celestialspa
    The intake form for Celestial Spa on Cloud 9 requests personal information such as name, contact details, date of birth, anniversary, employer, and how the client heard about the spa. It asks about any recent injuries, surgeries, medical conditions, medications, and reasons for seeing a doctor. The client is asked to indicate any current or past medical conditions and sign acknowledging the limits of massage therapy and the spa's cancellation policy.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Massage Intake

    Uploaded by

    Celestialspa
    40 views1 page
    The intake form for Celestial Spa on Cloud 9 requests personal information such as name, contact details, date of birth, anniversary, employer, and how the client heard about the spa. It asks about any recent injuries, surgeries, medical conditions, medications, and reasons for seeing a doctor. The client is asked to indicate any current or past medical conditions and sign acknowledging the limits of massage therapy and the spa's cancellation policy.

    Original Description:

    Intake Form

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    © © All Rights Reserved

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    The intake form for Celestial Spa on Cloud 9 requests personal information such as name, contact details, date of birth, anniversary, employer, and how the client heard about the spa. It asks about any recent injuries, surgeries, medical conditions, medications, and reasons for seeing a doctor. The client is asked to indicate any current or past medical conditions and sign acknowledging the limits of massage therapy and the spa's cancellation policy.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    40 views1 page

    Massage Intake

    Uploaded by

    Celestialspa
    The intake form for Celestial Spa on Cloud 9 requests personal information such as name, contact details, date of birth, anniversary, employer, and how the client heard about the spa. It asks about any recent injuries, surgeries, medical conditions, medications, and reasons for seeing a doctor. The client is asked to indicate any current or past medical conditions and sign acknowledging the limits of massage therapy and the spa's cancellation policy.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    Celestial Spa on Cloud 9

    Massage Therapy Intake Form


    Please print legibly

    (To be completed by therapist)

    First & Last


    Name___________________
    Email
    _____________________
    Phone
    (H)
    ___________________

    Birthday: ________________________________
    Anniversary: ________________________________
    Employer/Occupation: ________________________________
    Did you hear about us recently? ____________________
    How did you hear about us?

    (M)___________________
    (W)___________________

    If a friend or colleague, who?

    Please indicate preferred contact with a check

    ________________________________
    ________________________________
    Reason for visit: _______________________________________
    Receive reminder texts before yourFirst Professional Massage?
    Yes
    No
    appointment by listing your wireless serviceHow frequently do you get a massage? ____________________
    provider
    Verizon
    T-Mobile
    Other_________
    Please state any recent injuries, surgeries, accidents or medical treatments:
    _________________________________________________________________________________________
    _________________________________________________________________________________________
    __________________

    Allergies

    ___Neck/Spine Injury

    ___High Blood Pressure

    ___Liver Ailment

    ___Back Pain

    ___Low Blood Pressure

    Medications

    If you are currently seeing a


    doctor, please list reason(s):

    ___Kidney Ailment

    ___Sciatica/Leg Pain

    ___Skin Disorders

    ___Heart Ailment

    ___Carpal Tunnel

    ___Infectious Disease

    ___Fibromyalgia

    ___TMJ Syndrome

    ___Diabetes

    ___Cancer

    ___Sport Injuries

    ___Arthritis

    ___PMS Syndrome

    ___Headaches

    ___Cold/Flu/Fever

    ___Grief Process

    ___Varicose Veins

    ___Pregnancy

    Other:_____________

    Please check
    each condition that you currently have, and write (past) next
    to each condition that you have had in the past. You may also include how
    long ago.
    The above information is accurate and true to the best of my knowledge. I understand that massage therapists do
    not diagnose disease, prescribe medications or manipulate bones. I further understand that massage therapy is not
    a substitute for medical attention or examination. I take responsibility for alerting my practitioner to any physical,
    mental or emotional changes that occur with my health. I, also, understand that cancelled or missed appointments
    without 24 hours notice (medical emergencies excluded) may be charged in full for the price of the missed session.

    Signature: __________________________________

    Date:_______________________

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