Intake Form | Rolling Stone Elite

Massage Therapy

Intake Information

First name

Last name

Phone

Birthday

Month

Day

Year

Emergency Contact (Name / Phone)

Medical Conditions (check all that apply)

None

CARDIOVASCULAR / CIRCULATORY (high blood pressure, heart condition, blood clots/DVT, on blood thinners)

METABOLIC / AUTOIMMUNE (diabetes, autoimmune disorder, arthritis)

MUSCULOSKELETAL (recent surgery, herniated/bulging disc, joint replacement, osteoporosis)

OTHER (pregnant, cancer, skin condition)

Please describe any other illness / injury or condition(s):

Consent & Authorization:

I understand that massage therapy is not a substitute for medical diagnosis or treatment. I confirm that the information I provided is accurate and complete. I voluntarily consent to receive massage therapy services from RSEM & Wellness and agree to inform my therapist of any changes to my health or comfort during the session and that my personal and health information will be kept confidential and used only for treatment and administrative purposes.

Type your name here: This will serve as your electronic signature:

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