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Island Career Academy

Massage Therapy Clinic

New Patient Intake Form

Please complete all required fields before your first appointment. This information helps your student therapist provide a safe, effective session. All health information is kept confidential.

Need the separate printable clinic PDF or an accessible alternative to it? The source PDF remains available, and you can request the format that works for you.

View source PDF (opens in a new tab)Request accessible format
1

Personal Information

2

Emergency Contact

3

Reason for Visit

4

Health History

5

Lifestyle

6

Consent & Signature

I understand that massage therapy services at the ICA Massage Therapy Clinic are provided by student therapists under the supervision of a licensed instructor. I consent to the collection and use of the health information provided on this form for the purpose of planning and delivering massage therapy treatment. I understand that this information is kept confidential and will not be shared without my consent, except as required by law.