RIT Chair Massage Intake Form

Today's Date *

Name *
First *
Last *
Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Phone Number (Work) *

Phone Number (Mobile)

Work Email *

Health History
Your health information helps the therapist work with you safely and effectively.

Check all that apply:
 knee problems make it difficult to kneel 
 cold/flu/infectious disease 
 bruise easily 
 skin condition/rash/open cut 
 high or low blood pressure 
 recently had blood clots 
 lymph nodes removed 
 received radiation or chemo- therapy 
 surgery in the last 8 weeks 
 neck/spine problems 
 implanted medical devises 
 breast augmentation 
 fragile bones/osteoporosis 
 taking pain medications 
 chronic pain condition 
 heart condition 
Any other information regarding your health you would like to share?


Please check the YES box if you weigh more than 300 lbs, the maximum weight allowance for our massage chair. If so alternative arrangements can be made for your safety. *


Agreement. Please check here if you have read and agree to the following: I understand this massage is for relaxation and not for medical care. I am responsible for indicating to the therapist if I am uncomfortable or need to stop the massage at any time. *
 I Agree 

Voluntary Survey
At this time we have a male therapist at this time. For future reference we'd like to know if you have a gender preference for your massage therapist.

 No preference 

Submitting this form
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