Contact Information

Client Intake Form

Please complete the info below AFTER scheduling an appointment at our practice. Thank you!
Name *

First Name Last Name
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State

Zip Code
Personal Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Best email address to reach you *
example@example.com
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *

Area Code Phone Number
Profession
When is your scheduled appointment?
If you don't have one yet, please contact us at bintouchmassage@gmail.com
How did you hear about us? *

Prenatal Intake
What trimester are you in today? *
Due Date: *

Month Day Year
Is your pregnancy considered to be high-risk? *

Yes, this is a high-risk pregnancy. No, this is not a high-risk pregnancy.
Please describe high-risk reasons below: *
Have you had any problems or complications in this pregnancy? *

Yes, I've had problems or complications. No, I've not had problems or complications.
Please describe problems or complications below: *
Prenatal Massage Therapy Benefits: There are several observed or identified potential benefits to massage therapy during pregnancy, including:
- Relieves muscular tension, especially in the lower back, upper back, shoulders and neck
- Reduces stress on weight-bearing joints
- Enhances body awareness for better posture and less discomfort
- Assists with body mechanics and movement during structural change
- Supports birth process by relaxing muscles involved in labor and birth
- Eases anxiety and stress during time of transition
- Provides emotional support and nurturance
Prenatal Massage Therapy Contraindications: Performing massage therapy during pregnancy is contraindicated for women experiencing any of the following symptoms/signs:
- Bloody discharge
- Continual abdominal pains
- Sudden gush or leakage of amniotic fluid
- Sudden, rapid weight gain
- Increased blood pressure
- Severe back pain that does not subside with change in position
- Visual disturbances
- Severe nausea and/or vomiting (cannot keep anything down)
- Severe headaches
- Excessive hunger and thirst
- Fever
- Diarrhea
- Excessive swelling in arms or legs
- Decrease in fetal movement over a 24-hour period
- Additional conditions – phlebitis, thrombosis, or suspected clotting conditions, any kidney, liver or spleen compromise or infection. Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.
For our clients’ safety, we require a doctor’s release form in order to receive massage therapy during a high-risk pregnancy, which includes, but is not limited to:
- Early labor, miscarriage threat, placental or cervical dysfunction
- Gestational Edema Proteinuria Hypertension (GEPH)
- Preeclampsia
- Gestational Diabetes
- Pre-existing cardiac, renal, connective tissue or liver disorders/diseases
- Fetal genetic disorders
- Complications in previous pregnancies
- Three or more miscarriages
We also require a doctor’s release form in order to receive massage therapy during the first trimester.

Please read and sign below, to continue with treatment:

I understand that massage therapy is a health aid and does not take the place of a physicians’ care. Any information exchanged during a massage session is confidential and is only used to provide the best massage care. If I am having or develop any complications, I will discuss with my massage therapist.

I hereby voluntarily release B In Touch Massage Therapy and its therapists from any liability should my condition be aggravated at any time. By signing below, I agree that I have read the information above and have decided to receive a prenatal massage at my own risk.

I have received and understood the information on these pages about the benefits and possible contraindications of massage therapy during pregnancy, and confirm that:
- I have not experienced any the complications listed;
- I have not experienced any of the conditions listed, which would make it unwise to have massage therapy;
- I am experiencing a low-risk pregnancy;
- I am receiving medical care including regular check-ups throughout my pregnancy.
- I AM experiencing a high-risk pregnancy or have decided to have a 1st trimester massage, but have given a doctor’s release form to my massage therapist
I have received and understood all of the above information. *

I understand.
Signature *

Personal History
Have you had massage therapy before? *

Yes No
Major condition/complaint you'd like to improve: *
AREAS TO FOCUS: *
AREAS TO AVOID: *
Do you smoke? *

Yes No
Average hours of sleep per night: *
How often do you exercise? *
Weekly caffeine consumption: *
Weekly alcohol consumption: *

Policies and Disclaimer
Scheduling & Cancellation Policy: We understand that life can be busy – and we’re thrilled that you reserve time with us to relax! Please arrive a few minutes ahead of your appointment time, so that you receive your full session on the massage table. Our therapists reserve the right to end a session at the scheduled time.

If you need to cancel an appointment, we kindly request that you do so within 24 hours. The time slot that we reserve for you is yours alone, and we are often unable to re-book it if you cancel at the last minute. If you need to cancel with less than 24-hours’ notice, please try to send someone in your place, as payment will still be required for the session. Our appointment reminder emails and calls are a courtesy only; if you do not receive a reminder, please know that you are still responsible for keeping your appointment.

Disclaimer: Massage Therapy is not a substitute for medical treatment and/or medications. Our staff does not diagnose illness or disease, prescribe medications, or perform spinal manipulations. In certain cases of acute illness or injury, a doctor’s note may be required for us to proceed with therapy/treatment. Clients are expected to inform their therapists of all known physical conditions, medical conditions and medications. Our therapists access and review this form and choose appropriate treatments based on the materials disclosed herein. In some cases, our therapists will suggest avoiding certain treatments or the entire session altogether if he/she feels that the therapy may be detrimental to your condition. We are not liable for issues that may occur as a result of a client choosing to continue with treatment.

Payment & Refund Policy: Payment is due upon completion of each session. We accept cash, checks and all major credit cards. When purchasing packages or gift certificates, please make checks payable to B In Touch Massage Therapy. Checks for single sessions can be written out to your massage therapist. We do not accept Traveler’s Checks. All purchases are transferable, but non-refundable.

Please keep your personal belongings with you. We are not responsible for lost or stolen items.
Are you over 18 years old? *

Yes No
If no, please enter the name, phone number, and email address of your legal guardian. Please also have them email bintouchmassage@gmail.com indicating that we have their permission to work with you.
I understand all of the above information and have informed the Massage Therapist of all my known medical conditions and medications. I will keep my Massage Therapist updated of any changes. *

I understand.
Signature *
Should be Empty:

Client Intake Form

Health History

Prenatal Intake

Personal History

Policies and Disclaimer