Preview, not a live form

This is a static preview of the pre-session health intake form Miaise clients receive after they consent to SMS at booking. Real intake links use 32-character single-use tokens that expire after 7 days and submit only to the booking therapist. See our SMS consent documentation for the capture and revocation flow.

For your session with Jasmine

Pre-session health intake

Helps your therapist tailor the session and avoid anything that could harm you. Your responses are stored under HIPAA-grade encryption and visible only to your therapist.

About you

What brings you in today?*

A few sentences is plenty: pain points, goals, or just "general relaxation."

Current overall discomfort (0 = none, 10 = severe)*

012345678910

Health history

Helps your therapist work safely. Skip anything you prefer not to share.

Surgery in the last 6 weeks?*

YesNo

Are you taking blood thinners or anticoagulants?*

YesNo

Have you had a deep vein thrombosis (DVT) or blood clot in the last 6 months?*

YesNo

Are you currently in active cancer treatment (chemo, radiation)?*

YesNo

Have you been diagnosed with osteoporosis or osteopenia?*

YesNo

Pregnancy

Are you currently pregnant?*

YesNo

Session preferences

Pressure preference*

LightMediumFirmDeepLet my therapist decide

Anywhere you would prefer your therapist NOT work?

Consent

I consent to receive massage therapy. I understand I can withdraw consent or modify pressure / areas at any time during the session.*

YesNo

Type your full name as your signature*

Submission is disabled on this preview. Real forms encrypt answers in transit and at rest.