Wild Marigold Wellness

Client Intake Forms

Please complete the appropriate form below before your appointment. All information is kept strictly confidential.

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Client Information

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Session Details

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Health History & Medical Information

Condition Yes No Details (if yes)
Cardiovascular issues (heart disease, high/low blood pressure, pacemaker)
Cancer or currently undergoing chemotherapy / radiation
Diabetes (Type 1 or Type 2)
Nerve damage or neuropathy
Skin conditions (eczema, psoriasis, rashes, open wounds)
Muscle or joint injuries (sprains, strains, fractures)
Recent surgery (within the past 6 months)
Herniated or bulging disc / sciatica
Osteoporosis or bone fragility
Blood clots / DVT / varicose veins
Fibromyalgia or chronic pain condition
Autoimmune condition (Lupus, MS, Rheumatoid Arthritis, etc.)
Migraines or frequent headaches
Respiratory conditions (asthma, COPD)
Allergies to oils, lotions, or fragrances
Currently pregnant or possibility of pregnancy
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Areas of Focus & Avoidance

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Informed Consent & Agreement

Massage therapy is not a substitute for medical diagnosis or treatment. Your therapist will review this form with you before beginning. You may pause or stop at any time.

  • The information I have provided is accurate and complete to the best of my knowledge.
  • I will notify my therapist of any discomfort, pain, or changes during the session.
  • I understand the nature and purpose of massage therapy as discussed with my therapist.
  • I consent to receive massage therapy and to be draped according to professional standards.
  • I consent to the collection and storage of this information for the purpose of my care.
I have read and agree to the above informed consent. I confirm that all information provided is accurate. *
Your form will be sent securely to Amber before your appointment.
✓

Form received — thank you!

Amber will review your intake form and reach out to confirm your appointment details. See you soon.

1

Client Information

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Pregnancy Status

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Physician / Midwife Clearance

Massage is generally safe during pregnancy, but certain conditions require medical clearance. Please consult with your healthcare provider before your first session, particularly in the first trimester or if you have a high-risk pregnancy.

Condition Yes No Details (if yes)
Have you received clearance from your OB/Midwife for massage therapy?
Are you currently classified as a high-risk pregnancy?
Do you have or have had preeclampsia or gestational hypertension?
Have you experienced preterm labor or threatened miscarriage?
Do you have placenta previa or placental abruption?
Do you have gestational diabetes?
Have you had any bleeding or unusual discharge during this pregnancy?
Do you have symphysis pubis dysfunction (SPD) or pelvic girdle pain?
Do you have diastasis recti?
Do you have or have had a blood clot (DVT) during this pregnancy?
Are you carrying multiples (twins, triplets, etc.)?
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General Health History

Condition Yes No Details (if yes)
Cardiovascular conditions (heart disease, high/low blood pressure)
Varicose veins (massage contraindicated directly over varicose veins)
Skin conditions or heightened sensitivity (eczema, rashes, stretch marks)
Nerve pain, numbness, or tingling (sciatica, carpal tunnel)
Headaches or migraines
Swelling / edema (location and severity are important)
Nausea or motion sickness
Allergies to oils, lotions, or fragrances
Any recent surgery or medical procedure (non-pregnancy related)
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Areas of Focus & Positioning Preferences

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Post-Natal Specific Information (complete if postpartum)

Condition Yes No Details (if yes)
Have you been cleared by your OB/Midwife for postpartum massage?
Did you have a cesarean section? (If yes, is incision fully healed?)
Are you experiencing postpartum depression or significant mood changes?
Are you breastfeeding? (We can provide supportive positioning)
Do you have perineal tears, episiotomy, or areas still healing?
Do you have mastitis or breast engorgement?
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Informed Consent & Agreement

Pre-natal and post-natal massage is provided for relaxation and general wellness. It is not a substitute for medical care. Your therapist will use positioning and techniques adapted for pregnancy and postpartum recovery. You may pause or stop the session at any time.

I have read and agree to the above informed consent. I confirm that all information provided is accurate. *
Your form will be sent securely to Amber before your appointment.
✓

Form received — thank you!

Amber will review your intake form and reach out to confirm your appointment details. See you soon.

🔒

Your Privacy Matters

All health information you provide is kept strictly confidential and is used only to help Amber provide safe, effective care. Your information is never shared with third parties without your written consent.