Breckels Massage Therapy, Inc. Client Intake Form
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1Breckels Massage Therapy, Inc. Client Intake Form
Name _ ________________________________ _ P hone H)____________________C)_____________________
Address _________________________________________ City_____________________ Zip_____________
Date of Birth____________
E-Mail Address_____________________________________________________
Emergency Contact___________________________________________________Ph. ____________________
Would you like text message appointment reminders? If yes, what is your mobile carrier? __________________
Optional: What is your gender (circle one): Transgender
Female
Male
Other Gender
Identity
How did you hear about us?
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Internet____________
Facebook
Gift Certificate
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Grosse Pointe News
Location/DriveBy
Local Business
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Doctor Referral
Another Client
Name____________
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Yelp
Name_____________
Other_______________
Massage Questionnaire
Have you had a massage before? _________ Do you need help getting on or off the table?__________
Areas therapist should concentrate on: ____________________ Areas to avoid?___________________
Do you prefer deep, medium, or light pressure? ___________________________________________________
Do you have pain today? ____________ Explain __________________________________________________
Goal for today’s session ______________________________________________________________________
What is your music preference? (circle one or more)
Classical Guitar Jazz Piano Vocal Flute Chill-Electronica Minimal/Meditative No Music Other________
Health History
Do have a history of any of the following?
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Heart Disease
Blood Disorders
Fibromyalgia
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Seizures
Allergies
Wear Contacts
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Lung Disorders
Diabetes
Vision
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Cancer
Arthritis
Hearing loss
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Circulatory Problems
High Blood Pressure
Pregnancy-Number of weeks____
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Immune Deficiency
Osteoporosis
Skin Problems
If you checked any of the above, please explain
Have you had any surgery, trauma or accidents in the past two years? If yes, please explain
Do you have any other medical problems or concerns that you think your therapist should know about?
Please know that your massage therapist is not a physician and cannot diagnose, prescribe or treat any physical or mental illness,
and that nothing said in the course of the session should be construed as such. Because massage should not be performed under
certain medical conditions, please state all known medical conditions and answer all questions honestly. Please keep us updated as
to any changes in your medical profile and understand that there shall be no liability on the practitioner’s part or the part of
Breckels Massage Therapy, Inc. shall you fail to do so. Your medical condition may be shared with other therapists on staff;
however any other information you choose to share with your therapist will be kept confidential.
POLICIES: PLEASE INITIAL
_____ 2 4 hour’s notice is required to cancel an appointment, otherwise client will be charged the full cost of the appointment.
If you have incurred 3 (paid) no-shows or late cancels within 6 months, you will be expected to pre-pay for all future appointments. You
may also “walk-in” to see if we have anything open at any time, but you will not be able to reserve an appointment time on our schedule
without paying for it first.
I f your account remains active and in good standing for 6 months, the pre-pay stipulation will be removed from
your account.
______If a client is late for an appointment, the therapist will give as much time as he/she can, but will charge the full cost of the
appointment.
______Any illicit or sexually suggestive remarks or behavior made will result in immediate termination of the session,
and the client will be liable for the payment of the scheduled appointment and the police will be notified immediately.
I agree and understand the above policies.
Sign ____________________________________________________ Date ____________
Practitioner’s Signature _____________________________________Date____________
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