Client Intake Form | Etherealness Massage Therapy

First name

Last name

Year of Birth

Contact number

Email

Have you received massage before?

Yes

No

Are you on any medication?

Yes

No

Do you have any medical conditions?

Yes

No

Are you Pregnant?

Yes

No

Do you have any allergies or sensitivities?

Yes

No

Do you have any areas of discomfort ? is yes please list

Please add here any areas you would NOT like to be massaged (ie feet,stomach,ears etc)

I agree the the above information is accurate and to the best of my knowledge and give permission to be massaged today. I agree to inform the therapist if I experience any pain or discomfort during the session. I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment nor perform spinal manipulations. I will inform the therapist of my current condition at the time of each visit.

I understand Etherealness is a professional massage therapy service and any inappropriate requests/gestures will not be tolerated and reported.