Please complete this form prior to your massage treatment. Thank you so much and we look forward to seeing you soon!

Preliminary Client Intake



    Phone Number:*



    Company / Job Title / Brief Description of work*:

    Notes (Area of need, recent injuries, surgeries, allergies, and diseases or complications)*:

    Are Home & Billing the same?*

    If the answer is 'No', what is the accurate billing address?:

    I consent to receive bodywork support from SMART Bodywork® team (et. al.), Brian Keene LMT and if ever a dispute arises, I agree to seek arbitration and/or mediation between parties rather than filing a lawsuit.*

    *required field

    SMART Bodywork® Massage Services

    If you or someone you know is dealing with a sports or medical injury, give the SMART Bodywork® team of amazing massage therapists a try. With the many attributes, experiences and educations we are committed to helping you all the way through life achievements! Look forward to seeing you soon!


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