CONFIDENTIAL NEW CLIENT INTAKE FORM
NAME:____________________________________________________DOB:____/____/____________________________________________
ADDRESS: ___________________________________________________________________________________________________________
CITY: ________________________________________________STATE:________________________ ZIP: ____________________________
PHONE: (HOME) ______________________________________ (WORK) ____________________________________________________
DO YOU WEAR CONTACT LENSES:_________________ HEARING AIDS__________________ DENTURES _____________
LIST ANY SURGERIES OR INJURIES AND THE APPROXIMATE DATE:
ARE YOU ALLERGIC TO ANYTHING?___________________________
(FEMALES ONLY) ARE YOU OR COULD YOU BE PREGNANT AT THIS TIME?
Y/N____________________________________________
ARE YOU CURRENTLY OR HAVE YOU EVER EXPERIENCED THE FOLLOWING HEALTH CONDITIONS:
ASTHMA ________________________CANCER ______________________________DIABETES ____________________________
VARICOSE VEINS ________________ PHLEBITIS ____________________________ BLOOD CLOTS _____________________
SKIN CONDITIONS _______________ SEIZURES __________________ HEADACHES _______ HOW OFTEN? ________
ARTHRITIS _____________________ FIBROMYALGIA__________________________ DISLOCATIONS ___________________
HIGH OR LOW BLOOD PRESSURE _________Prescription?__________ HEART CONDITIONS ___________________
DO YOU HAVE ANY COMMUNICABLE OR CONTAGIOUS CONDITIONS?
CoVID-19 : Have you had this disease? __________ Been tested? ________ Could you have this disease?_________
EMERGENCY CONTACT: ________________________ PHONE # ________________________
To the best of my knowledge, the information given is complete and accurate. I understand that my massage
therapist cannot prescribe any medications, diagnose or treat any medical conditions.
MISCONDUCT: I also understand that this is a professional establishment and that any situation that
causes discomfort to the massage therapist will be reason for termination of services given.
Signature: ____________________________________ Date: ________________Driver’s License # __________________________
BE IN THE KNOW
Jot down your info and we’ll keep you updated on everything happening On The River (if you haven’t been
receiving our emails/newsletters please sign up again)
EMAIL ADDRESS: ______________________________________________________________ PHONE #_______________________
HOW DID YOU HEAR ABOUT ME? _______________________________________________________________________________