Medical Intake Form

“Touching lives, sharing love and care in your safe space.”

Medical Intake Form

For Spa Mobile's Clients who booked an in-home massage.

First Name

Last Name

Name of the person who took the appointment.

It is helpful to know which appointment is associated with you.

There is no need to add a name if you booked for yourself.

First Name

Last Name

Your basic information

Some description about this section

Email

Phone/Mobile

Date of Birth

Address

Address Line 1

City

State

Zip Code

Country

Which Therapist did you choose?

Which language are you most comfortable?

French

English

Do you need an insurance receipt?

Yes

No

Day-to-day Habits

This will help us know your day-to-day postures based on work and habits.

What is your work?

You are...

Left handed

Right handed

Both

Health Form

This information will help us understand your health conditions if there are any risks to receiving a massage.

Have you had any accidents/falls which left any aftereffects or pain?

Yes

no

If yes, please explain

Do you have skeletal-muscle problems?

Yes

No

If yes, please explain

Have you undergone operations (Surgery) that left after-effects or pain?

Yes

No

If yes, please explain

If other, please list it.

Do you take medication?

Yes

No

If Yes please list it.

Do you have varicose veins?

Yes

No

If Yes please inform us where they are. The massage therapist can't put pressure on them and it's important to know where they are before the massage.

Are you pregnant?

Yes

No

If yes, how many weeks? If you are under 12 weeks unfortunately we can't massage you.

Do you play sports? Or do any type of Physical Activities?

Yes

No

If so, which exercise do you regularly do?

Special Requirements

Help us customize your massage with those questions.

Which parts do you want MORE FOCUS on during your massage session?

If other please explain

What areas of your body do you want to AVOID during your massage session?

If other please explain

What pressure do you like? If you booked a relaxation massage and like it very deep we recommend you book a deep tissue. As not all our massage therapists are able to do a deep tissue.

Light Pressure Very Deep
0	1	2	3	4	5	6	7	8	9	10

Reason for a massage

Music Preferences

Conversation Preferences

Do you have any other things about your health that we should know?

Where did you find us?

Consent and Waiver

I authorize the use of lotion, oil, and ointments to my body

I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.

I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.

I release Spa Mobile for any responsibility in case of an accident, illness or injury.

I acknowledge that all information i provided in this form is true and accurate.

ONLY FOR THOSE WITH MEDICAL CONDITIONS. I acknowledge that I have consulted a physician before undergoing this treatment.

How our services work

1) BOOKINGS ARE DONE ONLINE

2) FIRST TIME RECEIVING AN IN HOME MASSAGE?

3) CUSTOMIZE YOUR MASSAGE

4) CANCEL OR RESCHEDULE

5) THE MASSAGE DAY

6) INSURANCE RECEIPTS

Where do we go?

IN-HOME MASSAGE

OFFICE MASSAGE

HOTEL MASSAGE

OLD AGE RESIDENCE

HOSPITAL MASSAGE

PRIVATE PARTY / EVENTS

SPORT MASSAGE

REFLEXOLOGY

LYMPHATIC DRAINAGE

FACE MASSAGE