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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

Medical Conditions*

Are you currently experiencing any severe pain?*

No Yes

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*