Elbow Room Massage Therapy
Client Intake Form
Alex Adamczyk, LMT · GA License #MT013193
Inside Stauffer Chiropractic
4595 Towne Lake Pkwy, Bldg 300, Ste 100
Woodstock, GA 30189
elbowroommassage.com

Fill this out before your appointment so your hour goes to the table, not the clipboard. It takes about five minutes and goes straight to Alex. Fields marked * are required.

Today

Chair or table? *

Client Information

Your Visit

Currently under chiropractic care?

Health History

Are you pregnant?

Please check anything you have or have had

This helps us work safely. Checking a box does not always mean we cannot work, it just tells us where to take care.

Areas of Focus

Tap a body area to cycle through pain, tension, and please avoid. Tap again to clear. Or just describe it below.

Head Neck Chest Abdomen Right arm Left arm Right leg Left leg Front
Head Neck Upper back Lower back Left arm Right arm Left leg Right leg Back
Pain Tension / tightness Please avoid

Pressure preference

Massage History & Preferences

Had massage before?

Informed Consent

I understand that massage therapy is provided for relaxation, relief of muscular tension, and general well-being. The therapist does not diagnose illness or disease, does not prescribe, and massage is not a substitute for medical care. I have shared all relevant health information and will tell the therapist of any changes. I will stay draped except for the area being worked, and I understand I may adjust pressure, decline any technique, or stop the session at any time. I am voluntarily seeking massage from Elbow Room Massage Therapy and consent to treatment.
Date

Typing your name here is your electronic signature. The date, time, and device used are recorded with your submission.

Goes directly to Alex's inbox. Nothing is stored on this website.

Got it. Thank you.

Your intake is in Alex's inbox. There is nothing else to do before your appointment. If anything changes, just mention it when you arrive.

Back to booking · elbowroommassage.com

Your health information is kept confidential and used only to provide and coordinate your care. If you tap Speak to dictate an answer, the dictation is processed by your browser's own speech service (on Chrome and Android that is Google's; on iPhone, Apple's) and the form only receives the text.  •  Elbow Room is not accepting clients under 18 at this time.  •  Printable version