MT Intake

Wild Wellness

Massage Therapy Intake Form

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Date of Birth *

Phone Number *

Emergency Contact *

First

Last

Phone Number *

Have you received professional massage therapy before? *

Yes No

If "yes," how often, and how long ago was your last session? *

Understanding that different areas of the body often prefer differing depths of pressure, if "yes," what is your general preferred depth of pressure? *

Light Medium/Firm Almost painful

What is your reason for seeking massage therapy? Check all that apply. *

Please Describe: *

Do you experience chronic or persistent physical pain or discomfort? *

Yes No

If "yes," where and for how long? *

Are there any areas of your body you prefer to not be touched? *

Yes No

Do you allow yourself regular physical activity? If so, how often? *

Medical History

Do you currently regularly see a physician? *

Yes No

What is the cause or contributing factor(s)? *

If "yes," please list here: *

If "yes," please describe: *

I understand, as massage therapy is both a medical and holistic healthcare profession, and in order to receive optimum treatment, the importance of my full disclosure. By entering my electronic signature below, I agree that all the information presented herein is comprehensively accurate to the best of my current knowledge.

Name *

First

Last

Date *

Submit