Client Intake Form

Thanks for choosing S.A.M. clinic for your massage. Please complete this form before your first appointment. It helps us tailor your session safely.

S.A.M clinic intake form

Contact InformationFull Name * Email * Phone * Emergency Contact Name Emergency Contact Phone Occupation

Visit DetailsReason for Visit / Goals for This Session Areas of Pain, Tension, or Injury Preferred Pressure Have you had a professional massage before?

Yes No

Health HistoryCurrent Medical Conditions Current Medications / Supplements Allergies (oils, lotions, latex, etc.) Recent Surgeries or Injuries Are you currently pregnant?

Yes No N/A

Anything else the therapist should know?

Consent I understand massage therapy is provided for relaxation and/or therapeutic purposes and is not a substitute for medical care. I have disclosed all relevant health information above and consent to receive massage therapy. * Type your full name as your signature *

Client Intake Form

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