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Client intake form

Before Your Appointment

Please complete this form before your visit. It helps us understand your wellness goals, health history, and any areas that need special care — keeping your session safe, professional, and personalized.

Why we need this

  • Comply with New Jersey massage therapy regulations
  • Ensure your safety and comfort during the session
  • Identify any contraindications or areas to avoid
  • Customize pressure and technique to your needs

RAKSA Intake Form

All information is kept confidential and used only to provide you with safe, professional massage therapy.

RAKSA Intake Form

1. Client Information

How we reach you and identify your record.

2. Session Preferences

Help us tailor your massage experience.

3. Health History

Your safety is our priority. Please share anything that may affect massage therapy.

⚠️ If you have any condition that may be contraindicated (blood clots, infectious disease, recent surgery, severe osteoporosis), we may request a physician’s approval before your session.

4. Client Acknowledgement (Required by NJ Law)

Massage and bodywork therapy practices are designed to promote and maintain the health and well-being of the client. Massage and bodywork therapies do not include the diagnosis of illness, disease, impairment, or disability. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or manipulations may be adjusted to my level of comfort. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all my known medical conditions and will keep the therapist updated as to any changes in my medical condition.