(813) 841-7767

Massage Intake Form

    Client Name:
    Referred by:
    ADDRESS
    CITY
    STATE
    ZIP CODE
    HOME PHONE
    CELL PHONE
    MALE/FEMALE
    BIRTH DATE
    AGE
    MARITIAL STATUS:S/M/D/W
    EMAIL
    DRIVER’S LIC. #:
    WORK/BUSINESS:
    WORK PHONE
    Can you be called at work about appointments?
    Whom do we contact in an Emergency?
    PHONE
    Relationship:

    Are you under a Doctor’s care?

    Dr.
    Doctor’s address
    Phone

    Are there any Chronic Problems? WHAT?

    Do you have any heart problems? WHAT?

    Do you have Diabetes? What Type? How Long?

    Do you have Kidney or Bladder problems? What?

    Do you have Chronic Pain? Where? Constant/Intermittent/How long have you Had this?

    Allergies/Sensitivities?

    Present Medications:

    Please describe your chief Complaint(s), at this time:

    Please relay any information that may interfere with receiving massage: (active, Cancer, broken bone, pregnancy, etc..)

    I will be paying for my Massage(s) by
    CashCheckCredit CardGift Certificate

    Your appointment time(s) are reserved for you. 24/72 hours notice is required to cancel an appointment. If unable to fill the cancelled/missed or frequently reschedule appointment, you may be required to pay for appointments. No Refunds on Gift Certificates or Pre-paid packages.

    MM12748/MA23791