New Client Intake Form

A few minutes now helps your therapist tailor pressure, technique, and focus safely to you. This is required before your first appointment.

Your detailsFull Name

EmailPhone

Date of Birth

Health history

Please check any that apply to you. Review our full contraindications list for more detail.

PregnancyHigh or low blood pressureHeart conditionBlood clots / DVT / circulatory conditionDiabetesCancer (current or in treatment)Recent surgery (within 6 weeks)Recent injury, fracture, or sprainSkin condition, rash, or open woundAllergies to oils, lotions, or nutsOsteoporosisPacemaker or implanted medical deviceRecent Botox or injections (within 2 weeks)

Please describe any conditions checked above, or other health notesCurrent medications (optional)

Your session preferencesAreas you'd like the therapist to focus onAreas to avoid (optional)Preferred pressure

I confirm the information above is accurate to the best of my knowledge, and I understand massage is not a substitute for medical care. I will inform my therapist immediately of any discomfort during the session.

Elysium Massage

Luxury, licensed in-home massage therapy across Los Angeles.

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Serving Los Angeles

Westside · Hollywood · Downtown · Pasadena · The Valley

embooking26@gmail.com

(805) 864-3853