New Client Intake

Your Details

The basics so we can reach you.

Full name *

Date of birth

Phone *

Email

Address

Emergency contact

Emergency phone

Occupation

How did you hear about us?

Preferred name

Pronouns

Had professional massage before?

If so, how often?

Check anything that applies — now or in the past. This keeps your session safe.

If pregnant — how many weeks / which trimester?

Current medications

Allergies (oils, lotions, scents, latex…)

Injuries, surgeries, or conditions we should know about

Are you currently under a physician's care? If so, for what?

Tell us where to focus and how you like your bodywork.

Mark where it hurts

Front

Back

Tap the body to mark a spot · tap a mark to remove it

Areas you'd like focused on

Areas to avoid

Pressure preference

Light Medium Firm Deep

Current pain / discomfort level

NoneSevere3

Primary reason for today's visit / goals

Please read and acknowledge.

I have read and consent to treatment, and confirm the information above is accurate. I have read and agree to the cancellation & deposit policy.

Signature — type your full name *

Date