Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Preferred Phone

(###)

###

####

I would like to receive periodic news and specials via email

Emergency Contact

Emergency Phone

(###)

###

####

Have you ever had a professional massage before?

Yes

If yes, how often do you receive massage therapy?

Do you have a preferred massage modality?

Select all that apply

Swedish Massage

Deep Tissue/Therapeutic

Prenatal Massage

Trigger Point Massage

Sports Massage

Cranial Sacral Therapy

Reflexology

Energy Work

Unsure

Do you have a preference for stroke pressure?

Light Pressure

Medium Pressure

Deep Pressure

Trigger Point Therapy

Energy Work

Other

Do you have sensitive skin?

Yes

Are you sensitive to fragrances or perfume?

Yes

Do you wear contact lenses?

Yes

Do you exercise regularly?

Yes

What are you common areas of pain, tension, or discomfort?

Do you suffer from chronic or persistent pain/discomfort?

Yes

If so, for how long?

Do you know what causes your pain, or what causes the symptoms to get better or worse?

Please explain in detail

Do you see a chiropractor?

Yes

If so, for how long?

Are you currently under medical care?

Yes

Are you currently taking any medication?

Yes

If so, for what?

Please explain:

Informed Consent & Massage Policies

I understand that the massage I will be receiving is for the purpose of stress reduction, relive from muscular tension or spasm. I understand that the massage therapist does not diagnose illness, disease, or any further physical or mental disorders. As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulations. I understand that massage is not a substitute for medical treatment or diagnosis and that it is recommend that I see a physician for any physical ailments that I may have. I acknowledge that the information I have provided on this form is correct and current to the best of my knowledge. I understand that it is my responsibility to inform the massage therapist of any changes to this information. I understand that if I experience any unusual discomfort and/or pain during my massage sessions it is my responsibility to inform the massage therapist so they can adjust the pressure or technique being used. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

All written records and massage sessions are kept strictly confidential and will not be shared with any outside establishment, individuals, organizations or medical facilities without explicit written consent from the client (you) or the client’s legal guardian. Unless legally required by local, state, or federal subpoena, summons, or other court order.

I have fully ready and understand this agreement.

Thank you! I look forward to seeing you at your first appointment. Please reach out if you have any questions beforehand.

With love, light, and joy,
~ Lisa Ramirez, LMT

Intake Form

Lisa Patrick LMBT #20299

Hours