New Client Intake Form – Mobile Massage San Diego

Full Name

Email *

Phone *

Date of birth

Preferred Contact Method *

Text

Call

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Address for Session

Emergency Contact

Which session length did you select?

Are you considering massage therapy as part of your ongoing wellness routine? *

Yes — I’m interested in making this a regular part of my self-care (weekly or bi-weekly sessions)

Maybe — I’d like to experience a session first and see how it fits into my routine

Not at the moment — I’m just booking a one-time session for now

Please describe any current or past medical conditions we should be aware of (e.g., high blood pressure, heart issues, surgeries, chronic pain, etc.):

Are you currently taking any medications? If so, please list them and note if they impact circulation or muscle response:

Do you have any allergies (lotions, oils, latex, etc.) or skin sensitivities we should be aware of?

Are there any physical conditions or injuries we should avoid or work around?

Professional Conduct & Elicit Acts Policy

Mobile Massage San Diego enforces a strict zero-tolerance policy for any inappropriate or elicit behavior.

Massage therapy is a professional therapeutic service. Any verbal or physical suggestion of sexual activity or misconduct will result in the immediate termination of the session, full payment due, and potential reporting to local authorities.

By signing this form, you acknowledge and agree to uphold the professional boundaries and conduct expected in therapeutic bodywork services.

I understand that massage/bodywork is intended for relaxation and therapeutic purposes only. If I experience any pain or discomfort, I will inform the therapist immediately. I understand the massage therapist does not diagnose illness, disease, or prescribe medical treatments. I confirm that I have answered all questions honestly and to the best of my knowledge. I also acknowledge that I have read and agree to the elicit acts policy above.

Date *

Client Signature *

Clear