New Client Profile

First name

Last name

Primary Phone Number

Birthday

Year

Month

Day

Please provide the approximate date of your last therapeutic massage

Year

Month

Day

Do you have any current medical conditions or injuries?

Yes*

If Yes, please specify

Please provide us with details, eg) recent surgeries, chronic pain, or musculoskeletal issues.

Are you currently taking any medication?

Yes*

If Yes, please specify

Please provide us with details as some medications may affect circulation, sensitivity, or healing.

Are you currently pregnant?

Yes

Areas of concern

Are there specific areas of concern that you would like us to address? Do you have any areas of pain, tension, or discomfort you'd like me to focus on or avoid?

Do you have any allergies or sensitivities to oils, lotions or scents used during massage?

If yes, please provide details

Have you had any recent illness, infections or fevers?

If yes, please provide details

Is your visit a result of a motor vehicle accident or workplace injury?

If yes, please provide details

Are you planning to submit your massage visit to an Insurance provider? and If yes, what is the name of the Insurance provider?

If yes, please specify the name of the Insurance provider

Name of Referring Professional (if applicable)

Referring Professional phone # (if known)

We'd Love To Know . . .

How did you hear about us?

Name of Referral (if applicable)

Knowing how you found us, or who recommended our services, helps us grow. If you provide the name of the individual that referred you - we go out of our way to thank them!