Author: emvarney

Client Intake Form ~ Erin’s Therapeutic Touch, llc

Name Phone
Address
City/State/Zip DOB
Emergency Contact Name & Phone #
Have you had a professional massage before Yes or No
Do you have any difficulty lying on your front or back Yes or No
Do you have any allergies to oils, lotions, or ointments Yes or No
Are you currently under medical supervision Yes or No
If yes, please explain
Do you see a chiropractor Yes or No
Are you currently taking any medications Yes or No
If yes, please list
Please circle any areas you would like me to concentrate on during the session.
Is there any area you don’t want massage?
Draping will be used during the session-only the area being worked on will be uncovered. Clients under 18 years of age must be accompanied by a parent of legal guardian during the entire session.
I understand that the massage I receive is provided for the basic purpose of relaxation & pain relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure &/or stoke may be adjusted to my level of comfort. I have also read & understand the payment policy.
This massage is NOWAY sexual! If you insinuate it is in anyway the session will end & you will pay in full.
Signature of client Date