Intake Form Keva Massage – Mobile Massage Therapy Intake form for Keva Massage clients. Required before service. "*" indicates required fields Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Emergency Contact Phone Number of Emergency ContactAre you currently under medical treatment?* Yes No MD, Chiropractor, Acupuncture, etc.Which one(s)? Do you have currently have or recently had any of the following conditions?* Diabetes Auto Immune Disease Headaches High Blood Pressure Arthritis Skin Conditions Heart Conditions Cancer Heart Disease Varicose Veins PTSD None of these Consent* I understand and agree to the following:I understand that massage therapy involves neither the diagnosis nor treatment of any condition and is not a substitute for medical care. Draping will be used for the entirety of the session. This is a full body massage unless otherwise requested. Neither breasts nor genitalia will be massaged. (Breast massage will be performed with the written consent of the client.)Consent* I understand and agree to the following:If I am uncomfortable for any reason, I may request to end the session and it will end promptly. If I engage in inappropriate behavior including hateful comments. the massage therapist will end the massage and I will be responsible for the full price of the massage. If a client is under the age of 17, written consent from a guardian or parent is required. I affirm that I am able to receive massage therapy and that any information provided above does not prohibit me from doing so. I understand that if I have medical diagnosis that prohibits me from receiving massage, I must provide a physician’s written consent prior to services.Client Signature*Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NameThis field is for validation purposes and should be left unchanged.
