Intake Form | Keva Massage

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Please fill out the fields below. Or, [download the intake form here] and email completed form to keva@kevamassage.com

Feel free to ask any questions, and I look forward to working with you!

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Name *

First

Last

Email *

Phone Number *

Occupation

Gender *

Male
Female
N/A

Are you currently under medical treatment? *

If under medical treatment, please explain below:

Do you currently have or previously had recently any of the following conditions? *

Diabetes
Autoimmune Disease
Headaches
Arthritis
Pregnancy
PTSD
Skin Conditions
Heart Conditions
Cancer
Heart Disease
Varicose Veins
Sprains/Strains
None

Please select all that apply. Or "None" for no conditions.

If you have or previously had a different condition than the ones listed above, please specify:

Consent Statement 1 *

I understand and agree with the following statement:

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.

Consent Statement 2 *

I understand and agree with the following statement:

If I am uncomfortable for any reason, I may request to end the session and it will end promptly. 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.

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