Massage Session Intake Form

Your Name

Your Email

Contact Number

Type of Massage (Select one )*

Health Information

Are you currently taking any medication if yes please list

Have your any allergies (e.g. oils, scents, lotions )

Areas to focus on or to avoid

Consent & Agreement

I confirm that the information provided is accurate and I consent to receive massage therapy.

I understand massage therapy is not a substitute for medical treatment.

Signature