Intake Form

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Heather Farrell, C.M.T.

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Client Intake Form

Name*

Email Address

Telephone Number*

What are your goals for this treatment? Please be detailed.

Last Menstrual Cycle or Estimated Due Date or Delivery Date or Injury Date

Last Menstrual Cycle is for potential Fertility Massage clients. Estimated Due Date or Delivery Date is for Prenatal/Postpartum/Scar Massage clients. And Injury Date would be for Therapeutic Massage clients.

Have you had a professional massage before*

YesNo

List all medications / allergies / surgeries.*

It is important that I am aware of medications, allergies and/or surgeries to make sure that it is safe for you to receive massage.

Referral?

Who can we thank for referring you to us?

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Please complete prior to your scheduled massage session.