Kinetic Relief Massage

Client Intake Form

Full Name *

Email *

Phone *

Date of birth *

Street Address *

City

State

Country

Postal Code

Emergency Contact *

Emergency contact phone *

Therapist *

Please answer the questions below

How did you learn about us? *

Have you received massage therapy or bodywork before? *

Yes

No

Are you on any medications? *

Yes

No

If yes, which ones

Do you exercise? *

Yes

No

If yes how many times per week?

How many hours?

I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment not perform spinal manipulations. I willT & C*I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment not perform spinal manipulations. I will inform the therapist of my current condition at the time of each visit. inform the therapist of my current condition at the time of each visit.

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