Client Intake Form

If you are a new customer.

Please fill out the following form prior to your appointment

Name

Email

Describe your lifestyle. Are your mostly

Active

Somewhat Sedentary

Sedentary

Phone

Occupation

Please select the area of focus

Front Upper Body

Front Lower Body

Back Upper Body

Back Lower Body

Head

Neck

Left Side Upper Body

Left Side Lower Body

Right Side Upper Body

Right Side Lower Body

What are you hoping to accomplish today? Explain

Please list your meds to surgeries that may be helpful to know about or could affect your treatment today.

The completed form signifies that you understand your massage therapist is providing a professional massage service. No one is a doctor, nor does anyone claim to prescribe or treat any illness or disease. You also understand that it is your responsibility to update us on important medical changes that may affect the outcome of your sessions. Payment of all services are to be paid at the time of service.

Initials

Thanks for submitting!

GET IN TOUCH

We'd love to work with you

MassageExperienceFW@gmail.com

260-739-7281

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