First Massage Visit Form

Fields marked with a * are required

Massage Intake Form


Please fill this form out before your first massage visit. This information will help us better serve you! Thank you.

Please answer the questions to the best of your knowledge.

Medical History Information

I, (client's name in the digital signature field below) understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension.  If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure may be adjusted to my level of comfort.  I further understand that the massage should not be construed as a substitute for medical examination, diagnosis , or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of.  I understand that the massage therapist are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness.  Because massage should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions honestly.  I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.  This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the schedule treatment.

Signature of Massage Therapist & Date.



Office Use Only


Pressure (1-10)