To submit this form, you may send it via email to info@douglasvillemassage.com or fax it to 555-123-4567. You can also submit it through our online portal available at www.douglasvillemassage.com/forms. For physical submissions, please bring the completed form to our office located at 8697 Hospital Drive, Suite 202, Douglasville, GA 30134. It's recommended to submit your form at least 24 hours before your appointment for proper processing.

The Intake Form remains valid as of 2024 and 2025. Be sure to submit an updated form if there are any significant changes to your health or treatment preferences. Regular reviews of your information help maintain accuracy for the best healthcare delivery.

The purpose of this Intake Form is to gather critical health information from clients prior to their initial treatment. This ensures that massage therapists can provide individualized care, addressing specific health concerns and preferences. It also serves as a record of the client's medical history which may impact therapy.

• 1. First Name: The client's first name.
• 2. Last Name: The client's last name.
• 3. Email Address: The client's email contact.
• 4. Home Phone #: The client's home phone number.
• 5. Street Address: The client's residential address.
• 6. State: The state where the client resides.
• 7. Emergency contact name: Name of the emergency contact.
• 8. Emergency contact relationship: Relationship to the client.
• 9. Emergency phone #: Phone number of the emergency contact.
• 10. Date of initial visit: The date for the first therapy session.
• 11. General health rating: Client's self-assessed health rating.
• 12. Medications: List of current medications and their purposes.
• 13. Allergies: Any known allergies.
• 14. Date of birth: Client's date of birth.
• 15. Referred by: Source of referral.
• 16. Mobile Phone #: Client's mobile phone number.
• 17. Work Phone #: Client's work phone number.
• 18. City: City of residence.
• 19. Zip Code: Postal code.
• 20. Physician's name: Name of the client's physician.
• 21. Physician's phone #: Contact number for the physician.
• 22. Massage experience: Prior experience with professional massage.
• 23. Accidents or surgeries: Details of any major accidents or surgeries.
• 24. Reason for visit: Primary reason for the therapy session.

If the form is not submitted, your appointment may be delayed or denied. It is crucial to provide all necessary health information to facilitate appropriate care. Clients are encouraged to ensure all fields are filled accurately prior to submission.

• Incomplete Information: Failing to provide all requested details could result in missed health risks.
• Delayed Appointment: Not submitting the form might delay the scheduling of your massage.
• Safety Risks: Lack of critical health details can increase risks during treatment.

• 1. First-Time Clients: All individuals experiencing massage therapy for the first time should complete this form.
• 2. Health Updates: Clients who have had changes in their health should submit an updated form.
• 3. Return Clients: Returning clients may need to fill this out if there have been previous health concerns.