Please complete this form before your massage therapy session.
Healthcare template · 13 fields (9 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
Set up your massage therapy intake form
Please complete this form before your massage therapy session.
Review health notes before each session and update the form yearly. Keep answers minimal and use a HIPAA-appropriate setup if you bill insurance or store health records.
The form separates phone number, date of birth, type of massage requested, areas to focus on into labeled questions. Review the choices and required fields for your organization before sharing it.
Best practices
Review health notes before each session and update the form yearly. Keep answers minimal and use a HIPAA-appropriate setup if you bill insurance or store health records.
Customize the phone number and date of birth questions to match your records and terminology.
Name the team that reviews responses and explain what happens after submission. A requested date, service or approval is not automatically confirmed.
Ask only for information needed for this step. Arrange any sensitive supporting documents through an appropriate private process.
Every field, explained
Your full name (Name, required)
Email address (Email, required)
Phone number (Phone, required)
Date of birth (Date, required)
Type of massage requested (Dropdown, required)
Areas to focus on (Multiple choice)
Areas to avoid (Multiple choice)
Preferred pressure (Single choice, required)
Current medications, injuries or health conditions (optional) (Long text)
Allergies, including to oils or lotions (optional) (Short text)
Are you pregnant? (Single choice, required)
Emergency contact name and phone (Short text, required)
Confirmation (Multiple choice, required)
Frequently asked questions
What does this massage therapy intake form template collect?
Alongside contact details, it asks for phone number, date of birth, type of massage requested, areas to focus on, areas to avoid, preferred pressure, current medications, injuries or health conditions (optional), allergies, including to oils or lotions (optional), are you pregnant?, emergency contact name and phone, confirmation. You can rename questions, change choices and remove fields that your workflow does not need.
How should I use this massage therapy intake form form?
Review health notes before each session and update the form yearly. Keep answers minimal and use a HIPAA-appropriate setup if you bill insurance or store health records.
Can I edit this form and print a copy?
Yes. Open an editable draft, adjust the questions, and review the preview before publishing. You can also use the template page’s print option. Publishing requires an account; the draft can be tried first.