918-525-2960

Massage Therapy Intake Form

Personal Information

Name

Phone Number

Address

Birthdate

Email Address

Occupation

How did you hear about us?

Medical Information

Are you currently taking any medications?

If yes, please list name and use:

Are you currently pregnant?

If yes, how far along? Any high risk factors?

Do you suffer from chronic pain? If yes, please explain.

What makes it better?

What makes it worse?

Have you had any orthopedic injuries? If yes, please list:

Please indicate any of the following that apply to you.

Cancer

Stroke

Headaches/Migraines

Heart Attack

Arthritis

Kidney Function

Diabetes

Blood Clots

Joint Replacement/s

Numbness

High/Low Blood Pressure

Sprains or Strains

Neuropathy

Fibromyalgia

Please explain any conditions you listed above:

Massage Information

Have you had a professional massage before?

What type of massage are you seeking?

A good massage is deep enough that it feels good to you, but not so deep that you are in pain. Generally speaking, on a scale of 1-10 what depth of pressure/intensity do you prefer? 1 being light pressure, 10 being deep pressure.

Do you have any allergies or sensitivities? If yes, please explain:

Are there any areas (feet, face, abdomen, etc.) you do not want massaged? If so, please list:

What are your goals for this treatment session? 

We are 100% committed to your satisfaction. Please read and agree to each policy to ensure you have a GREAT experience with us.

I understand I must arrive 5-10 minutes early for my appointment in order to get the full session time I have scheduled. If I arrive on time or late I understand the therapist can only give me whatever time remains of my appointment and that I will pay for the full length of the session that I booked. *

I understand that in order for me to receive the best massage therapy possible, I know that I have to communicate ANYTHING and EVERYTHING, including my needs, preferences, requests or feedback, at any time before, during or after my massage. I take it upon myself to communicate right away if there is anything distracting me or if I feel unwell or uncomfortable at any time during the session so that adjustments can be made. I understand my therapist wants my HONEST feedback, positive or negative, and doesn't take offense to it. *

A 24 hours notice is required for any cancellations/rescheduling. Call or text

918-525-2960 anytime and leave a message. *

Cancel or change your appointment with at least 24 hours notice: no problem, no charge. *

Cancel or change within 24 hours notice of your appointment for any reason: $35 cancellation fee, or 50% of the full session rate (whichever is greater). You can avoid this by sending someone in your place! *

Cancel or change your appointment within two hours: full charge unless we can rebook that slot. *

Thank you!