Levvit Massage intake

First name

Last name

Email

Phone (type +1 for U.S.)

Date of birth

Month

Day

Year

Occupation

Emergency Contact Name & Relationship to you

Emergency Contact Phone (type +1 for U.S.)

Health History

1. Have you received professional massage/bodywork before?

yes

no

2. Please indicate if you have any of the following: (Check all that apply)

3. Please describe any current medical conditions or relevant surgeries:

4. Are you under the care of a physician?

yes

no

5. Are you currently taking any medications or supplements?

Yes

No

1. What type of massage/body therapy are you receiving today?

2. What are your main goals for this session? (e.g. reduce swelling, relieve pain, improve circulation):

3. Are there any specific areas of discomfort or tension? Please describe:

4. Are there any areas of your body you would like avoided?

I understand that ..

By checking this box, I confirm my electronic signature and acceptance of this agreement.

Date signed