Authorization Intake Form for Massage Therapy

Welcome to NYC Massage and Spa! 🌿

Greetings! We’re delighted to have you with us. Our commitment is to provide you with unparalleled service, ensuring your massage therapy experience is relaxing, rejuvenating, and holistic. To aid us in tailoring our services to your unique needs and preferences, we kindly request you to fill out our Authorization Intake Form.

Full Name*

Date of Birth*

Age*

Gender*

Occupation*

Address*

City*

State*

ZIP*

Your Email*

Your Phone*

Emergency Contact Name*

Emergency Contact Phone*

Health Information

Do you have any medical conditions (e.g., diabetes, high blood pressure, heart conditions, allergies, etc.)? If yes, please specify*

Are you currently taking any medications? If yes, please list*

Have you had any surgeries or injuries in the past year? If yes, please describe*

Are you pregnant or trying to become pregnant? (If applicable)*

Yes

Do you have any areas of pain, discomfort, or specific areas you would like the therapist to focus on during the massage?*

Have you received massage therapy before? If yes, please describe your experience*

Massage Preferences

What type of massage do you prefer? (e.g., Swedish, deep tissue, sports, etc.)*

Are there any specific areas you would like the therapist to avoid during the massage?*

Do you have any allergies to massage oils or lotions? If yes, please specify*

Is there anything else you'd like to communicate to your therapist before the session?*

Acknowledgment*

I acknowledge that I have completed this intake form to the best of my knowledge and have provided accurate information regarding my health and preferences for massage therapy. I understand that the information provided will be kept confidential and used solely for the purpose of providing safe and effective massage therapy.

Client's Signature (Initials)*

Date*

Add ID (jpg, jpeg, png, gif up to 4mb size)*

This field should be left blank