PASSION MOBILE MASSAGECLIENT INTAKE & INFORMED CONSENT FORMProfessional Massage Therapy at Your DoorstepClient InformationFull Name: __________________________________Phone / WhatsApp: ___________________________Email: ______________________________________Date: _______________________________________Massage Location: ☐ Home ☐ Hotel ☐ Office ☐ OtherEmergency Contact & Phone: ___________________
1. HEALTH & MEDICAL INFORMATIONTo ensure your safety and comfort, please answer the following questions honestly.Do you currently have or have you experienced any of the following?☐ High or low blood pressure
☐ Heart condition
☐ Diabetes
☐ Recent surgery or injury
☐ Muscle or joint pain
☐ Back or neck problems
☐ Skin infection, rash, or open wounds
☐ Blood clotting disorder or history of blood clots
☐ Allergies (including oils, lotions, or fragrances)
☐ Pregnancy
☐ Fever or contagious illness
☐ None of the aboveAre you currently taking any medication?☐ Yes ☐ NoIf yes, please specify: __________________________Are there any other medical conditions, physical limitations, or concerns your therapist should know about?
2. MASSAGE PREFERENCESPreferred Massage Type:☐ Swedish Massage
☐ Deep Tissue Massage
☐ Hot Stone Massage
☐ Prenatal Massage
☐ Sports Massage
☐ Couples Massage
☐ Thai Massage
☐ Other: ______________________Preferred Pressure:☐ Light ☐ Medium ☐ FirmAreas requiring special attention:☐ Neck & Shoulders
☐ Back
☐ Legs & Feet
☐ Arms & Hands
☐ Full Body
☐ Other: ______________________Areas to avoid during treatment:
3. INFORMED CONSENT & CLIENT DECLARATIONPlease read and acknowledge the following:I understand that massage therapy is intended to promote relaxation, comfort, and general wellness. It is not a substitute for medical diagnosis or treatment.I have provided accurate and complete information about my health and medical history.I understand that I must inform my therapist of any changes in my health before or during the session.I understand that massage may not be appropriate for certain medical conditions, and my therapist may modify, postpone, or decline treatment where necessary for safety.I understand that I may request adjustments to pressure, technique, or positioning, and may pause or stop the session at any time.I understand that professional draping will be maintained throughout the session. Only the body areas being treated will be exposed. Intimate areas will never be massaged.I acknowledge that massage therapy is strictly professional. Any inappropriate behaviour or request may result in immediate termination of the session.4. PRIVACY & CONFIDENTIALITYI understand that the personal and health information provided in this form will be treated confidentially and used only for service delivery, client safety, and relevant business administration, subject to applicable legal requirements.5. CLIENT CONSENTBy signing below, I confirm that I have read, understood, and voluntarily agree to receive massage therapy from Passion Mobile Massage.Client's Full Name: __________________________Client's Signature: ___________________________Date: ______________________________________Therapist's Name: ___________________________Therapist's Signature: ________________________
PASSION MOBILE MASSAGE
Your Comfort. Your Space. Your Wellness.
Website: passionmobilemassage.com
WhatsApp: +234 9127 414 105
