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Massage Therapy Appointment Form
Client Information
Client Name*
Client Address*
Street Address 1
Street Address 2

City

State/Province/Region

Postal/Zip Code

Country
Email*
Phone
--
Birthdate*
Emergency Contact
Name
Phone
Relationship
Do you have any allergies?*

Yes No

List allergies
Medical Conditions*
Are you currently experiencing any severe pain?*

No Yes

Please describe.
Massage Information
Form of Massage*
Type of Massage*
Full Body Focused Indivdual Couples
Length of Massage*
30 minutes 45 minutes 60 minutes
It is my choice to receive therapeutic massage therapy today. I have disclosed my pertinent medical conditions, and will update the massage facility of any changes in my health status.

I understand that my failure to do so may pose a threat to my health and physical well-being. I hold this facility and my massage therapist harmless from any liability whatsoever arising from failure to disclose on my part.

By signing below, I agree to the facility's policies and client agreement.
Client Signature*
Date*

Name	Phone	Relationship

Massage Therapy Appointment Form