Just Relax | Client Intake Form

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Contact us

918.791.1068

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Client Intake Form

Name:

Address:

Phone:

Email:

D.O.B.

Hobbies:

Occupation:

Have you ever had a professional massage?

Medical Considerations

Diabetes

Heart Disease

Asthma

Arthritis

Fibromyalgia

Pregnant

Cancer

Hard Contacts

Surgeries

Scoliosis

Kidney Disease

High Blood Pressure

Allergies

Skin Conditions

NONE

Current Medications

Any areas you want me to avoid?

Do you have any areas of pain or discomfort you would like addressed?

Name & Phone Number of Emergency Contact

Signature:

Parent/Guardian Signature for Minor

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