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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: June 28, 2022

First Customer Name

First Name*

Last Name*

Phone*
First Customer Date of Birth*
First Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
First Customer Signature*
Second Customer Name

First Name*

Last Name*
Second Customer Date of Birth*
Second Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Third Customer Name

First Name*

Last Name*
Third Customer Date of Birth*
Third Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Fourth Customer Name

First Name*

Last Name*
Fourth Customer Date of Birth*
Fourth Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Fifth Customer Name

First Name*

Last Name*
Fifth Customer Date of Birth*
Fifth Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Sixth Customer Name

First Name*

Last Name*
Sixth Customer Date of Birth*
Sixth Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Seventh Customer Name

First Name*

Last Name*
Seventh Customer Date of Birth*
Seventh Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Eighth Customer Name

First Name*

Last Name*
Eighth Customer Date of Birth*
Eighth Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Ninth Customer Name

First Name*

Last Name*
Ninth Customer Date of Birth*
Ninth Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
Tenth Customer Name

First Name*

Last Name*
Tenth Customer Date of Birth*
Tenth Customer Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
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

Emergency Contact's 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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

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:

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?
For your session, would you prefer:
Massage oil
Massage Lotion
Don't care
Would your prefer the massage room to be:
Light
Dim
Don't care
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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