Client Intake Form

First name

Last name

Email

Phone

Date of Birth

Month

Day

Year

Emergency Contact (Name and Phone)

Massage Experience

Have you ever had a professional massage before?

If, so: What types of massage/bodywork have you had?

What are your goals for today’s massage?

Current Health

Do you have allergies?

Yes

No

If yes, please describe:

Do you exercise regularly and/or participate in any sports?

Yes

No

If yes, please describe:

Have you recently suffered an injury?

Yes

No

If yes, please describe:

Do you have areas of inflammation?

Yes

No

If yes, please describe:

Are you currently taking blood thinners?

Yes

No

If yes, please describe:

Are you currently taking any substances that reduce your sensitivity to pain or impair your judgement?

Yes

No

Health History

Please Select Any/All of These MUSCULOSKELETAL Medical Conditions that Apply

Please Select Any/All of These CIRCULATORY Medical Conditions that Apply

Please Select Any/All of These RESPIRATORY Medical Conditions that Apply

Please Select Any/All of These NERVOUS SYSTEM Medical Conditions that Apply

Please Select Any/All of These SKIN CONCERNS & INFECTIONS Medical Conditions that Apply

Please Select Any/All OTHER Medical Conditions that Apply

Any other concerns or medical condition(s) that I should be aware of?

Requested Date for Massage

Book an appointment

October 2026

Week starting Sunday, October 25

Time zone: Coordinated Universal Time (UTC)Phone call

Thursday, Oct 29

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 1:00 PM

1:00 PM - 2:00 PM

Can't make it on Tuesdays? Let us know what days and time work best for you!

Policies

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that 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 of which I am aware. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. By signing below, I agree to the following:

Cancellation

A 24-hour notice is kindly requested for cancellation of an appointment.

Tardiness

Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. If you are late, the time will have to be cut from your massage time. Please call your massage therapist if there are concerns of running late.

Sickness

Massage is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition.

HIPAA

Carismatic Massage takes confidentiality seriously. At no time will the massage therapist share information related to you or your treatment with anyone. Anything discussed in the massage session will remain private, unless you pose a health threat to yourself or others.

Thank you for choosing Carismatic Massage. I appreciate your business and your understanding of these policies.

Signature

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Date

Todays Date

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INTAKE FORM

Client Intake Form