Massage Therapy Intake Form

Client Information

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Country/Region

Address

City

Zip / Postal code

Health History

Do you have any allergies or sensitivities (e.g., essential oils, lotions)?

Are you currently taking any medication?

Do you have any existing medical conditions? (e.g., heart conditions, diabetes, etc.)

Have you had any recent surgeries or injuries?

Do you have any chronic pain or discomfort?

Are you pregnant or trying to conceive?

Massage Preferences

What are your main goals for this massage? (check all that apply)

Areas of Focus (check areas you would like to focus):

Areas of Avoid (check areas you would like to avoid:

Massage Pressure Preference:

Light

Medium

Firm

Client Dress Code Policy

At DND Massage Therapy, we want you to feel comfortable and relaxed during your massage session. To ensure a positive experience for both you and your therapist, we ask that you adhere to the following dress code:

Comfortable Attire: We recommend wearing loose, comfortable clothing to your massage appointment. This allows for ease of movement and ensures maximum relaxation during your session.
Optional Attire: You may undress to your comfort level for your massage session. Many clients choose to undress completely, while others prefer to leave undergarments on. Please know that you will be appropriately draped with sheets or towels at all times during the massage, with only the area being worked on exposed.
Modesty and Privacy: Your privacy and comfort are our top priorities. Your massage therapist will step out of the room while you undress and get on the massage table. You will be given privacy to dress and undress before and after your session.
Communication: If you have any concerns or preferences regarding clothing during your massage, please don't hesitate to discuss them with your therapist. We are here to accommodate your needs and ensure a positive experience.
Hygiene: Please ensure that you are clean and free of any strong scents before your massage appointment. This helps create a pleasant and comfortable environment for both you and your therapist.
If you have a cold, flu, or any contagious conditions, please reschedule your appointment until you are feeling better. This ensures a safe and healthy environment for everyone.

By adhering to these guidelines, we aim to create a relaxing and professional atmosphere for all of our clients. If you have any questions or concerns about our dress code policy, please feel free to discuss them with your therapist.

This policy helps set clear expectations for clients regarding attire during massage sessions, while also emphasizing privacy, comfort, and communication.

Thank you for choosing DND Massage Therapy. We look forward to providing you with a rejuvenating massage experience.

Consent and Acknowledgment

I understand that massage therapy is a complementary health approach and is not a substitute for medical treatment or diagnosis. I have provided accurate and complete information regarding my health, and I agree to inform the therapist of any changes in my health status during the course of treatment.

By signing below, I consent to receive massage therapy treatment and acknowledge that I have been informed of any relevant contraindications for the session.

Signature

Date