top of page
Green Reflection

Client Intake Form

Thank you for choosing Petrissage Remedy! To ensure we provide you with the best possible service, please take a few moments to complete this intake form. 

All information provided will be kept confidential and used solely to assist you. If you have any questions or need help filling out the form, don't hesitate to contact us. 

We appreciate your time and look forward to working with you! 

​

Additionally, while massage therapy offers many benefits, there are certain health conditions for which massage is not appropriate and may pose risks. If you have any of the conditions listed below, we kindly ask that you reschedule/consult with your healthcare provider before coming in for the session. 

  • Fever

  • Diarrhea

  • Contagious illnesses (flu, common cold, influenza, COVID-19, mononucleosis, hepatitis A/B/C, norovirus, etc.)

  • Contagious skin conditions (shingles, chickenpox, impetigo, ringworm, scabies, lice, widespread yeast infection, etc.)

  • Active infections (bacterial, viral, or fungal)

  • Acute injuries or inflammatory conditions (severe burns, cellulitis, hives, rheumatoid arthritis flare-up, appendicitis, gastroenteritis, diverticulitis, etc.)

  • Undiagnosed rashes or contagious skin lesions

  • Blood clots/Deep vein thrombosis/Phlebitis

  • Hemophilia 

  • Recent major surgery (requires medical clearance)

  • Radiation therapy or chemotherapy (requires medical clearance)

Client Intake Form - Confidential

Birthday
Month
Day
Year
Multi-line address

Emergency Contact

Have you had professional massage before?

bottom of page