Intake form | Merinda Massage And

First name

Last name

Email

Phone

Please check any conditions that apply to you:

If Pregnant how many weeks along are you?

Are you currently experiencing any of the following?

Numbness or tingling?

Sharp or radiating pain

limited range of motion

None of the above

Please list any injuries or other health concerns

I understand massage therapy is not a substitute for medical treatment. I confirm that I have answered honestly and will inform the therapist of any health changes.

Type your full name as signature