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Total thail Wellness

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Massage Intake Form

Please take a moment to fill out the form.

First Name

Last Name

Address

Email

Date of birth

Occupation/Phone

Emergency Contact Name/Phone

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Are you currently pregnant? If yes, how many weeks? ( Massage is unsafe for YOU and BABY during first trimester )

Have you had a professional massage before? YES___ NO ___ If yes, how often do you receive massage therapy?

Date of birth

Thanks for submitting!

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