New Clients | INTAKE FORM

Client Intake Form

Your information helps me provide the safest, most effective care possible and will remain confidential.

Full Name *

Date of Birth *

Phone *

Email *

Address

Street Address

City

State

Country

Postal code

Emergency Contact Relationship to You *

Emergency Contact *

Emergency Contact Phone Number *

Your Occupation:

Referred By: *

Health Information:

Are you taking any medications?

Yes

No

If yes, please list medications:

Do you have any allergies? (oils, lotions, nuts, fruits, etc.)

Yes

No

If you have allergies, please list:

Are you currently pregnant?

Yes

No

If yes, please answer:

How many months:
Due date:

Are you currently under medical supervision or receiving other medical interventions?

Yes

No

If yes, please describe medical interventions/providers:

Areas of broken skin? (rash, wounds, etc.)

Yes

No

If yes, where?

History of joint replacement surgery?

Yes

No

If so, which joint(s)?

Recent injuries or medical procedures in the past two years?

Yes

No

If yes, please describe any injuries or medical procedures here:

Please describe any other injuries or health conditions:

Massage Information

Have you had a professional massage before?

Yes

No

If so, how recent was your last massage?

Reason for seeking massage:

Relaxation

Specific Problem

If a specific problem, please explain:

How much pressure do you prefer?

Light

Medium

Firm

By submitting this form, I consent to receive text messages and/or emails from Tranquil Essence. These messages may include appointment reminders and other important information. I understand the standard text messaging and data rates apply. I understand I may opt out of receiving these messages at any time by replying "STOP" to any text message or by contacting Tranquil Essence directly.

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