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Massage therapy client intake form

Please complete this form prior to your first session

Contact information

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Medical information

Please take a moment to carefully read the following list of conditions and questions below and check any that have affected your health either recently or in the past.

Circulatory | Lymph | Endocrine system
Nervous system
Musculoskeletal system
Digestive | Urinary system
Skin
Reproductive system
Respiratory system

Treatment requirements

Help us understand the main reason for seeking therapeutic treatment, so your session can be tailored to your specific requirements. 

Please indicate any areas you would like your therapist to focus on
Please indicate your preferred massage pressure

Declaration

Thank you! Your therapist will discuss your responses prior to your treatment.

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