New Client

Client Intake Form

Please complete this form before your first session. Your health history helps Emma provide safe, effective, and personalized care.

Personal Information

Health History

Check all conditions that apply. This information is kept strictly confidential.

Session Preferences

Preferred pressure

Areas to focus on (select all that apply)

Areas to avoid (select all that apply)

Informed Consent

I understand that massage therapy is intended for stress reduction, relief from muscular tension, or spasm reduction. I clearly understand that massage therapy is not a substitute for medical examination or diagnosis.

I have stated all my known medical conditions honestly and understand that providing inaccurate history could result in injury. I acknowledge that it is my responsibility to inform my therapist of any changes in my health status.

I understand that massage therapy is not a substitute for medical treatment and that my therapist does not diagnose illness, disease, or any other physical or mental disorder. I understand that massage therapy does not prescribe medical treatment or pharmaceuticals, nor does it perform spinal manipulations.

I give my consent to receive massage therapy from Emma Duncan, LMT at Mend Therapeutic Massage. I understand that I may end the session at any time if I feel uncomfortable.

Mend Therapeutic Massage

Clinical massage therapy for lasting relief — not just relaxation. Located at 10560 Main Street, Suite PS110, Fairfax, VA.

10560 Main Street, Suite PS110, Fairfax, VA 22030

Mobile Practice

Need massage therapy that comes to you? Visit my mobile practice serving Northern Virginia.

maisonmassagetherapy.com

Mend is my studio location. Maison Massage Therapy is my mobile practice — same expert care, wherever you are.

© 2026 Mend Therapeutic Massage. All rights reserved.

10560 Main Street, Suite PS110, Fairfax, VA 22030

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