VA Intake Form (Medical Massage)

Please fill out the following intake form. Once you have completed the form, you can proceed to the next step in receiving care: scheduling your appointment.

Personal Information

First name

Last name

Phone

Email

Birthday

Month

Day

Year

Emergency Contact

Medical Information

Are you taking any medication?

Yes

No

Orthopedic Surgeries?

Yes

No

Please explain any conditions selected above:

Medical Massage (Your Appointment)

Have you had a massage before?

Yes

No

What type of massage are you seeking today?

Medical

Please note that the only massage avaiable are medical massages.

Preferred pressure level

Light

Medium

Deep

Please note that the only massage avaiable are medical massages.

Are there any areas you do not want massaged?

Feet

Face

Abdomen

Other (please specify)

What are your treatment goals for this session?

Informed Consent

I understand that this massage is not a substitute for medical care and that no diagnosis will be made. I consent to receive medical massage treatment and agree to inform the therapist of any changes in my health.

Signature

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BRING OUT YOUR DIVINE