Let’s get to know youClient Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Birthday month and day How did you hear about me? Have you ever received a massage before? Yes No If yes, how often? What is your reason for getting a massage? (Please check all that apply.) Relaxation Experiencing back pain Experiencing pain in neck and/or shoulders Injury Lack of sleep Other Do you have any medical conditions I should be aware of? If yes, do you have medical clearance from your doctor to receive massage? Yes No Thank you!
