Please fill out this intake form before your first session with Body Exhale Mobile Massage Therapy.

Intake Form

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Do you have, or have you had in the past, any of the following conditions: (This information is strictly confidential and may be very important to your therapy.)
Type of massage you are requesting? ( Please select one or more below
Are you pregnant?
"I understand that massage therapy involves neither diagnosis nor treatment of any condition and is not a substitute for medical care. The session is a full body massage that includes the face, feet, and gluteus. Draping of the genital area and gluteal cleavage will always be used for all clients. The licensee shall drape the breasts of all female clients and not engage in breast massage of all female clients unless the client gives written consent before each session involving medical breast massage. If I or the therapist become uncomfortable for any reason, either person may request to end the session, and the session will be ended. Licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature."
I hereby give permission for medical breast massage.
If you are a new client: How did you find Body Exhale?

To be filled out by licensee:

Massage Therapy Information

I understand that massage therapy involves neither diagnoses nor treatment of any condition and is not a substitute for medical care. The session is a full body massage that includes the face, feet, and gluteus. Draping of the genital area and gluteal cleavage will always be used for all clients. The licensee shall drape the breasts of all female clients and not engage in breast massage of all female clients unless the client gives written consent before each session involving medical breast massage. If I or the therapist become uncomfortable for any reason, either person may request to end the session, and the session will be ended. Licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature.

Styled HR
Text Size Example To be filled out by licensee: