Binghamton Massage and Wellness

Personal Information

First Name:

Last Name:

Date of Birth:

Email:

Phone:

Emergency Contact:

Emergency Contact Phone:

How did you hear about Binghamton Massage and Wellness?

Medical History

Primary Physician:

Please list any medical conditions you have:

Please list any medications you are currently taking:

Are you currently pregnant?

Yes No

How far along in your pregnancy are you?

Have you ever had massage therapy before?

Yes No

How often do you receive massage therapy?

Consent and Signature

I understand that the massage therapist will not diagnose or treat any medical conditions. I have accurately provided information about my health history and any conditions that may affect my treatment. I consent to the massage therapy treatment discussed, and I am aware that I may stop the treatment at any time.

Date:

Binghamton Massage and Wellness Intake Form

Personal Information

Medical History

Reason for Visit

Consent and Signature