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Client Intake Form

Please complete our Client Intake Form before your first appointment at Massage Haven. This will help us get to know you better, including your general health and massage preferences, so we can provide the best experience possible for you. You may complete the online form below OR download the PDF form at the bottom of the page.

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Personal Information

Name
Date of Birth
Address
Please provide the name of your primary care physician plus location and/or phone number

Massage Preferences

Have you ever experienced a professional massage or bodywork session?
What kind of pressure do you prefer?

Medical Conditions

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. If you answer “yes” to any of the following questions, please explain as clearly as possible.

Do you frequently suffer from stress?
Do you have diabetes?
Do you experience frequent headaches?
Are you pregnant?
Do you suffer from arthritis?
Are you wearing contact lenses?
Are you wearing dentures?
Do you have high blood pressure?
Are you taking high blood pressure medication?
Do you suffer from epilepsy or seizures?
Do you suffer from joint swelling?
Do you have varicose veins?
Do you have any contagious diseases?
Do you have osteoporosis?
Do you have any allergies?
Do you bruise easily?
Any broken bones in the past two years?
ny injuries in the past two years?
Do you have cardiac or circulatory problems?
Do you suffer from back pain?
Do you have numbness or stabbing pains?
Are you sensitive to touch or pressure in any area?
Have you ever had surgery? Explain below.
Other medical condition, or are you taking any medications I should know about?
Do you have tension or soreness in a specific area?
Please enter additional details regarding the questions above, specifically those you answered YES to.

Your Consent

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examina- tion, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually sugges- tive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Who Are You Signing For?

If you prefer, you may also download our Client Intake PDF, print and complete it, then bring it to your first appointment.

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Location / Contact

Corinne Jewelers Plaza
917 Route 166
Toms River, NJ 08753

Phone: 732-240-0340
Email: massagehavennj@gmail.com

Spa Hours

Monday - Friday: 10 am - 8 pm
Saturday - Sunday: 10 am - 5 pm

Client Intake Form

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