New Client Intake Form | Moonstone Massage & Bodyworks

first visit form

Welcome! Please fill this out before your first appointment. When you're done you can send it to us, or print it and bring it with you. Prefer paper? Print a blank form.

Personal information

Name

Phone

Date of birth

Address

City / State / Zip

Occupation

Employer

Primary physician

Emergency contact

Relationship

Emergency contact phone

How did you hear about us?

Agreement I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Type your full name as your signature

Date

Therapist signature ______________________________ Date ____________

I understand that sending this form online delivers it to Moonstone by regular email, which is not encrypted. (If you'd rather not, just print it and bring it to your appointment.)

Fields marked * are needed to send the form. Everything else is optional, but helps us tailor your session.