Mobile Massage Therapy Intake Form

Please fill out this client intake form so that we may fully understand your needs before you begin your massage session.

First Name*

Last Name*

E-mail*

Mobile Number*

Address*

Where would you prefer massage therapy session?

My Place?
Your Place?

Any REPRODUCTIVE issues?

Pregnant
Given birth
Male Erection Problems

Is there any special requires need in order to make your massage therapy experience the best possible?

As massage therapists, we're all ethically bound to adhere to the principle of confidentiality. We agree to do that as members of professional associations like Associated Bodywork & Massage Professionals.

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage.

I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law.

I understand and consent that any information will not be shared to various care providers not involved in my care and treatment. I understand that it is my responsibility to confirm the exact details of my coverage.

Do you consent to proceed?

Yes
No