New Client Intake Form — Elana Martinez, LMT

Personal Information

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Date of Birth *

Please enter your date of birth.

Phone Number *

Please enter your phone number.

Email *

Please enter a valid email address.

Medical Information

Do you have any medical conditions? *

Yes No

Please choose Yes or No.

Do you have any allergies? *

Yes No

Please choose Yes or No.

Do you take any medication I should be aware of? *

Yes No

Please choose Yes or No.

Body Work

Specific goals or intention for your bodywork (massage or lymphatic drainage) *

Please share your goals or intention.

Are you currently experiencing any injuries or pain? *

Yes No

Please choose Yes or No.

Date of last massage (optional)

I'm interested in receiving bodywork in-home!

Additional Contact Information

Emergency Contact *

Please enter an emergency contact.

Relationship to You (optional)

Emergency Contact Phone Number *

Please enter your emergency contact's phone number.

If you were referred, please share by whom (optional)

I offer a discount on future sessions for referrals!

Consent

I have read and agree to the above consent *

You must agree to the consent before submitting.

Signature (type your full name) *

Please type your full name as your signature.