Intake Form - ICT Massage

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Fill out the form below to get started!

Items with * are required

Name *

Email Address *

Phone Number *

Secondary Phone Number

Address *

Address 2

City *

State *

Zip Code *

Date of Birth

Primary Physician

Emergency Contact

Your Relationship to Your Emergency Contact

Emergency Contact Phone

If you don't mind - where did you hear about ICT Massage?

Are you on any medication? *YesNo

Please list medications

Are You Pregnant? *YesNo

How far along is your pregnancy?Are there any risk factors involved with your current pregnancy?

Do you experience chronic pain? *YesNo

Please tell us about your chronic painWhat things improve your pain?What things make your pain worse?

Do you have any orthopedic injuries or surgeries of concern? *YesNo

Please list those injuries or surgeries

Do you suffer from any of the following conditions (Check all that apply)

CancerHeadaches / MigrainesArthritisDiabetesJoint Replacement(s)

NeuropathyFibromyalgiaStrokeHeart AttackHigh / Low Blood Pressure

Blood ClotsNumbnessKidney DysfunctionSprains or Strains

Please provide more information on your conditions if any

Have you ever had a massage before?YesNo

What type of massage are you seeking?RelaxationTheraputic / Deep TissueIf niether of the above, explain

How much pressure do you like?LightMediumDeepNot sure

Do you have any allergies or sensitivitiesYesNoIf yes, please explain further

Do you have areas of your body you don't want touched (for instance, stomach, feet, or other areas)YesNo

Describe what areas to avoid

What are your goals for your massages?

Signature:

By entering your name and clicking the accept checkbox below, you agree to the following:

‍I have completed this form to the best of my ability and knowledge, and agree to inform my massage therapist if any of the above information changes at any time.

Your full legal name *Today's Date *

Check to Accept *Accept

Thank you! Your submission has been received!

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about ICT massage

We are a professional massage service provider located in Wichita, Kansas. Explore the benefits of a more relaxed you, with ICT Massage!

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6803 S Broadway
Haysville, KS 67060 (316) 550-0950

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