Disclaimer
The information provided here is intended solely as a general example for intake procedures and client information collection. It does not constitute medical or professional advice and should not replace consultation with a qualified healthcare or wellness professional. Procedures and requirements may vary based on local regulations, licensing standards, or individual needs. Users assume full responsibility for implementing or modifying this template, and no liability is accepted for errors, omissions, or consequences resulting from its use without professional oversight.
This sample Massage Intake Form template is provided for illustrative purposes and may vary based on specific requirements and regulations. Please customize accordingly.
Massage Intake Form Template
Parties:
Massage Therapist: Sarah Lee
Address: 789 Wellness Lane, Los Angeles, CA 90001
Client: Michael Johnson
Address: 345 Oak Street, Los Angeles, CA 90002
Session Details:
Date of Session: ___________________________
Time of Session: ___________________________
Duration: ___________________________
Health History & Concerns:
Please list any relevant health issues, recent injuries, or concerns that may affect your massage therapy session:
Medical Conditions:
__________________________________________________________
Allergies or Sensitivities:
__________________________________________________________
Consent & Additional Instructions:
I confirm that the information provided is accurate and complete. I understand that I should inform the therapist of any discomfort or concerns during the session. I agree to the terms and conditions outlined by the therapist.
Client Signature: ________________________________
Date: ________________________________
Therapist Signature: ________________________________
Los Angeles, ______________________