New Client Intake FormPlease fill out to the best of your ability and click submit. Submissions are sent to Nicole’s Wholistic Health. Name * First Name Last Name Phone (###) ### #### Email * Date of Birth * MM DD YYYY Emergency Contact Name * in case of emergency Emergency Contact Phone Number * (###) ### #### Are you currently on blood thinners? or any heart medications? * Yes No Are you currently pregnant? * No Yes Do you suffer from chronic pain? If yes, please explain. describe your pain here Massage Information: Have you had a professional massage before? * Yes No What pressure do you prefer * Light Medium Deep Not sure Are there areas you do not want massaged? If yes, please indicate below. Do you have any allergies or sensitivities? If yes, please indicate below. By entering your name below you agree to the following statement: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above changes. * Thank you!
