Post-Operative Massage Intake Form
Please complete this form so we can understand your post-operative needs, recovery stage, and massage preferences before scheduling.
Client & Contact Details
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Surgery & Recovery Information
Surgery Type / Procedure Name
*
Surgery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Affected Area / Body Region
*
Please Select
Head/Neck
Shoulders/Upper Back
Chest
Abdomen
Lower Back
Arms
Hands/Wrists
Hips/Pelvis
Thighs
Knees
Lower Legs/Ankles
Feet
Multiple Areas
Other
Current Recovery Stage / Time Since Surgery
*
Less than 2 weeks
2–6 weeks
6–12 weeks
More than 12 weeks
Massage Readiness, Restrictions & Consent
Surgeon/Physician Cleared Massage
*
Yes
No
Post-Operative Restrictions or Areas to Avoid
Preferred Massage Goal or Main Concern
Submit
Should be Empty: