Name

First Name

Last Name

Phone

(###)

###

####

Occupation or everyday hobbies

If disabled, retired or homemaker, please feel free to share that as well as any daily activities. This may include any typical stressors that you experience daily (emotionally or physically) including repetitive movements.

Allergies

Please list any allergies or sensitivities you may have. Are you allergic to any oils, detergents, or smells?

Medications/Suppliments

Please list any medication or supplements that you are currently taking.

Current, Chronic or Occasional Health Conditions

Please list ANY and ALL health concerns you may have experienced, past, or present.

Favorite Scents, Oils & Lotions

I use organic non-scented Coconut, Grape Seed, Sesame and Almond Oils as well as Bio-tone lotion as massage product. To enhance your session aromatherapy is also available and can be added to any of these oils of choice. Please list your preferred scents to be used during your session. Non-scented is also always an option.

Non-Scented Only

On Guard (similar to thieves with cinnamon, Cloves, orange, etc)

Citrus Blends (Orange, Lime, Lemon, Grapefruit options)

Eucalyptus Blends

Mint Family

Sage, Lavender or Floral Blends

Chakra Balancing Blends (ask about this)

Ayurvedic Dosha Balancing Blends (ask about this)

Allergies to any of these products. Please contact me prior to our session so I can make sure the room is neutral for your sensitivities.

How can I best help you? What areas tend to be issues for you?

What is the most important thing that I can do to help you the most during your session? What would you like to get out of our time together?

18 or over - (if client is a minor, authorization and permission for services must be given by guardian).

Client is a minor. As parent or legal guardian, I authorize Laura Wheeler, LMT to provide massage therapy to said minor to promote wellness care.

Client is NOT a minor, I have signed electronically below.

I have fully read and understand this intake form. To the best of my ability I have answered all questions truthfully for either myself or the minor who is in my legal care.

Signature and Date

By electronically signing below,, you are authorizing Laura Wheeler, LMT to provide massage therapy to you or your minor as noted on this form. You are also releasing Laura Wheeler, LMT, of any liability financial or otherwise should symptoms unknown or previously known, be aggravated or inflamed. Massage therapy is intended to be beneficial to the body, mind and spirit. Although it is uncommon, there may be some brief discomfort, your massage session should not be painful. By signing this form, you state that you will let Laura Wheeler, LMT know if any aspect of the massage causes, discomfort or pain so that the session may be properly adjusted, advised to stop or guided according to your needs. You also state by signing this form that you have informed Laura Wheeler, LMT, of any illnesses, diseases or conditions that would make massage therapy inappropriate for your health to your best knowledge.

Name

First Name

Last Name

Date

YYYY

Thank you for taking the time to finish your intake form. This will help me to best serve you and take your needs into consideration. Should you have any questions prior to our session, please reach out. I am excited to work with you!

Massage Therapy Intake Form

You are grace. ♡