New Client Intake Form

Please take a minute to complete your health history below so your specialist can tailor your session and keep you safe.

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Name *

First

Last

Email *

yes, so, injuries?

Phone Number

Any allergies to essential oils? If yes, please list them. *

Any previous injuries? If so, where and when?

Any current injuries? If so, where, what type of injury, and when?

Has a doctor cleared you for massage therapy? *

• Yes
• No
• Not sure

Any current pain or swelling? If so, where?

Does any pain or injury affect your daily activities? If so, how?

Consent *

• I confirm the information above is accurate to the best of my knowledge.

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