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Massage Therapy Intake Form

Clinical intake form for licensed massage therapists. Includes detailed health history, pain assessment body map, and treatment consent.

Last updated: April 2026

Researched by the CheckinPulse Research Team

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This is what your clients will fill out. 23 fields, mobile-friendly.

Massage Therapy Intake Form

All fields marked with * are required

Text
Email
Phone
Date
Text
Text
Phone
Text
Phone
Describe your main issue
Text
Pain reduction
Arthritis, fibromyalgia, sciatica, herniated disc, carpal tunnel, TMJ, migraines...
High blood pressure, heart disease, blood clots, varicose veins...
Yes
Light
I consent to massage therapy treatment*
I have disclosed all relevant health information*
Sign here
Submit Form

Consent / Waiver Language

This waiver text is included at the bottom of the form, above the signature field.

I consent to massage therapy treatment by a licensed massage therapist. I understand that massage therapy is not a substitute for medical treatment and that the therapist does not diagnose medical conditions. I have disclosed all known medical conditions, medications, and health concerns. I understand I may request to stop the session at any time. I release the therapist from liability for complications arising from undisclosed health conditions.

Frequently Asked Questions

A "massage therapy" intake form is typically more clinical — it includes pain assessment, treatment goals, physician info, and detailed health history. It's designed for licensed massage therapists doing therapeutic or medical massage. A basic "massage intake" form works for spa and relaxation massage where the focus is on preferences rather than treatment planning.

Including a physician contact field is smart but making it required depends on your practice. For therapeutic or rehabilitative massage, having the doctor's info is important in case you need to coordinate care. For relaxation massage, it's optional. Insurance-covered massage often requires a doctor's referral anyway.

In most cases, no. Massage therapists aren't typically HIPAA-covered entities unless they bill through a health plan or work in a covered healthcare setting. But treating client health info as confidential is still best practice and builds trust. Your intake form should include a basic privacy statement.

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