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Areté Massage Intake Form 

Please fill out the form completely. We will never share your information with anyone without your consent. For any reason.

  • I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.
  • I understand that a massage therapist can not diagnose illness, disease, or any medical, physical, or emotional disorder, nor perform any spinal manipulation. I am responsible for consulting a qualified physician or physical therapist for any physical ailments that I have.
  • I understand that massage therapy is a therapeutic health aide and is non-sexual.
  • Some massages will require work around the gluteus Maximus, face, & head. If you’d prefer them to not be part of your massage, let your therapist know.
  • I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized.

Today's date: May 22, 2025

First Customer Name
First Name*
Last Name*
Phone*
First Customer Date of Birth*
Date of Birth
First Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
First Customer Signature*
Second Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Second Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Third Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Third Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Fourth Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Fourth Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Fifth Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Fifth Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Sixth Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Sixth Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Seventh Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Seventh Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Eighth Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Eighth Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Ninth Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Ninth Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Tenth Customer Name
First Name*
Last Name*
Phone*
Customer Date of Birth*
Date of Birth
Tenth Customer Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Customer Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above. Parents/ guardians are required to stay on premise while minor is in their session.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Preferred Pronouns
Occupation:
Referred By:

Massage Session Information 


What are your goals in seeking massage therapy?

What makes a massage great for you?
What type of pressure do you prefer?
Light
Medium
Deep

List any exercise activities & frequency:
Are you training for a specific event?
Are you currently receiving PT?*
No
Yes
If yes, what for?
Are you taking any blood thinners (Aspirin, Ibuprofen, Coumadin)?*
No
Yes

Previous History (include year & treatment received)

Have you had a recent surgery?*
No
Yes
If yes, when?
What for?

Prior Surgeries or history of cancer

Injuries/accidents/illness still affecting you:

Please mark any of the following that you now have or have had. 

Skin
Allergies
Rashes / Infections
Athletes foot
Topical hormone or pain cream

If allergies, please specify:
Musculoskeletal
Bone or joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw pain (TMJ)
Spinal Problems
Circulatory
Heart Condition
Phlebitis / Varicose veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombosis / DVT / Embolism
Other
Pregnant
Cancer / tumor
Breathing difficulty / Asthma
Diabetes
Migraines / headaches
If pregnant, what trimester?

Any other health concerns I should know about?

Essential oils may be used during your session, are there any scents you are averse to?
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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