Massage Intake Form Template – US

Disclaimer

The information provided is intended solely as a general example for an intake document related to massage therapy services. It does not constitute medical or legal advice and should not be relied upon as a substitute for consulting a qualified healthcare professional or legal expert specializing in wellness services. Regulations and requirements may vary by jurisdiction, and adjustments may be necessary to ensure compliance with local laws. The use of this example is the sole responsibility of the user, and we assume no liability for any errors, omissions, or consequences arising from its use without proper professional review.

Please note: This is a sample Massage Intake Form for US clients, intended for illustrative purposes only. Actual forms should be customized to meet specific needs and comply with applicable regulations.

Massage Intake Form (US Sample)

Client Information:

Name: ________________________________
Date of Birth: ________________________________
Contact Number: ________________________________
Email Address: ________________________________

Emergency Contact:

Name: ________________________________
Phone Number: ________________________________
Relationship: ________________________________

Medical History and Conditions:

Please list any medical conditions, allergies, medications, or injuries relevant to your massage therapy:

• Heart conditions, high blood pressure, or other cardiovascular issues
• Skin infections, rashes, or open wounds
• Allergies to lotions, oils, or other products
• Pregnancy or recent surgeries
• Other relevant health concerns

Massage Preferences and Goals:

Please specify your preferred massage types, areas of focus, and any specific goals or concerns:

Consent and Acknowledgment:

I acknowledge that I have provided accurate health information and understand the nature of the massage therapy. I agree to communicate any discomfort or concerns during the session.

Signature: ________________________________
Date: ________________________________

Location: ______________________