New Massage Client Intake Form

This form must be filled our prior to receiving services. This form is only filled out once. All follow-up visits will require a different intake form.

First name

Last name

General Information

Please read and agree to the following, and check the box below:

I agree that I am not under the influence of drugs and alcohol, and am of good mental health. I also agree that I am not currently sick with infectious rashes or illnesses, nor am I presenting any symptoms. I will let Cloud9 Spa of any health-related issues.
I agree to not purposefully go over my appointment time, to not partake in extra activities while on the premises, to not touch or change any equipment, decorations, or settings at Cloud9 Spa. I also agree to respect the policies, condition of premises, dispose of all garbage in the trash bins, and not destroy anything within the premises.

I agree to all the above.

Have you ever had a professional massage?

General Medical Information

List ALL known allergies, current conditions (serious or chronic medical conditions [such as diabetes, high blood pressure, blood clots, etc], pregnancy [& how far along, complications, & high risk or not]), etc, you have. If none, please skip.

List ALL medications, surgeries, etc. If not applicable, please skip.

Please list & describe ALL (physical/mental) symptoms you have today, if you have implants/rods/plates, etc, how/when they started, part of the body & activities affected. If none, please skip.

Preferences

Please list any and all therapy/product preferences. For example, oil preferences, pressure preferences, sensitivities, heated/non-heated table, type of massage, etc preferences. If none, please skip.

Let us know if you would like us to focus on an area or avoid an area. If not applicable, please skip.

Signature & Date

I agree that I am at least 18 years of age, and/or am attending with my minor child.

If you are signing this form for your minor child, please indicate your names and relation below. Please also sign in the signature block below. Skip if this does not apply.

If you are receiving a CBD massage, you must check this box and sign below to acknowledge that you understand that the oil being used is pure CBD and contains zero THC.

Signature

Signature field is empty.

Date

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Year

New Massage Client Intake Form

Location & Hours