Chair Massage Intake Form printable pdf download

Chair Massage Intake Form

Welcome!

Thank you for your interest in massage! Please fill out the information below and give

your completed form to the massage practitioner.

Name: _________________________

Work Phone Number: _________________

Email: ______________________________________________________________

What areas would you like addressed during your massage? ___________________

_____________________________________________________________________

Are you currently under a doctor’s supervision for any reason? Yes

If yes, please explain.

_____________________________________________________________________

Please read the following statement, then sign and date below to indicate that you have

read and understood the statement.

The practitioner is not responsible for the aggravations of conditions which were

present, but not disclosed, at the time of the massage and which may be affected

by the massage.

Signature: _____________________________ Date: ________________________

Chair Massage Intake Form