INTAKE FORM | Bree Massage

Full Name

Preferred Name

Pronouns

Birthday

Month

Day

Year

Phone Number

Email Address

Emergency Contact Name

Emergency Phone Number

Please tell me more about any areas of pain, tension, injury, or specific goals for your session.

Selecting a style does not mean it must be used during your session. Your treatment can be customized and may blend multiple techniques based on your goals, comfort, and needs that day.

Some enhancements may be incorporated when appropriate based on time, treatment goals, and availability.

Please explain anything checked above that would be helpful for your massage therapist to know.

Have you had any surgeries, significant injuries, or medical procedures that may affect your massage?

Are you currently under the care of a physician, chiropractor, physical therapist, or other healthcare provider?

Yes

No

If yes, please briefly explain.

Do you have any allergies or sensitivities to essential oils, fragrances, lotions, oils, liniments, heat, or other topical products?

Yes

No

If yes, please describe your allergies or sensitivities.

Have you received professional massage before?

Yes

No

When was your last massage?

Is there anything you have particularly liked or disliked during previous massages?

Your comfort and boundaries are important. You are encouraged to communicate at any time about pressure, temperature, positioning, areas you would like avoided, conversation level, or anything else that would make your session more comfortable.

Are there any areas you do NOT want massaged?

Is there anything else you would like BreeLyn to know before your session?

I understand that massage therapy is not a substitute for medical diagnosis or treatment. I have provided accurate information to the best of my knowledge and agree to communicate any changes in my health, comfort, or preferences. I understand that I may request changes to pressure, technique, positioning, or stop the session at any time.

Client Signature (type your full legal name)

Date

Corvallis, OR

Healing Arts at 5th & Monroe
Corvallis, OR 77330

Corvallis, OR

Healing Arts at 5th & Monroe Corvallis, OR 77330

Healing Arts at 5th & Monroe
Corvallis, OR 77330