Republic Of Wellness • 67 Coddington St. Suite 103 Quincy • MA 02169 • 617-481-1280
Customer Intake Form
Please fill out the following form
Customer Information
 
Full Name
 
Date Of Birth
 
Email
 
Occupation
 
Contact Information
Primary
 
Secondary





Address
 
City
 
State  
 
Zip        
 
Medical Information
All the information provided below will remain strictly confidential. For certain medical conditions or symptoms massage may be contraindicated. In such cases a referral from your primary care taker may be required prior to a session
Main reason for your appointment today
How did you hear about the Republic?

If other selected. Please tell us where:
Would you like to receive a birthday discount?
($20 off on any treatment during the month of your birthday - only for current clients)
Have you ever received professional massage?
How recently?
List all the likes & dislikes


If you answer 'Yes' to and of the following questions, please explain as clearly as possible in the lines provided below:
Do you frequently suffer from stress?
If 'Yes' then please specify stress level
Do you have diabetes?
Are you pregnant?
Do you suffer from Arthitis?
Do you have osteoporosis?
Do you have high blood pressure?
Do you suffer from Epilepsy or Seizures?
Have you been in accident or suffered any injuries in the last 2 years?
Do you have Varicose Veins?
Do you have any contagious disease?
Have you ever been bruised by massage?
Have you had any broken bones in the last 2 years?
Do you have any Cardiac Or Circulatory Problems?
Have you had any recent surgeries?
Do you have any other medical condition or are you taking any medications?
Do you have any known allergies?
Are you very sensitive to touch or pressure in any area?
Do you have TMJ?
Do you excercise regularly?
Do you excercise regularly?
Do you have numbness or stabbing pains anywhere?
Do you have any tension or soreness in a specific area?
If you answered yes to any of the above questions, please explain
Terms & Condition