Intake Form

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offered by raphaël beaupied, certified practitioner


Please fill out the form below faithfully

The intake form will help the massage therapist to better serve you by understanding your specific needs and being aware of any relevant information related to your medical condition (issues, medications, and contraindications). Please fill out the form faithfully. This will allow Raphaël to adapt the massage therapy accordingly and to offer the best experience possible.

Intake Form
All fields marked with an asterisk (*) are mandatory.

Please enter your full name*


Date of birth (DD/MM/YYYY)*

Please enter your profession*

Email address*

Phone number*

How did you hear about Kůra Růka?*

Have you ever had a professional massage before?*

If yes, what type of massage therapy?

If yes, how often do you receive massage therapy?*

What type of pressure do you normally prefer?*

Do you usually prefer music being played while you are receiving a massage? Note: If you answer ‘Yes’, your therapist Raphaël will play gentle and soothing ambient, handpan, or guqin music in the background during the therapy.*

Do you practice a sport / physical activity?*

If yes, which one?

Please check all that apply. I have / I had / I am / I was…*

Please provide as much detailed information as possible about the conditions that you previously checked above.*

Please indicate any other relevant information that might be useful to the massage therapist, such as areas of discomfort/tension that you would like Raphaël to focus on, or areas he should avoid during your session (i.e. due to past trauma).*

By signing this form, I confirm the truthfulness of this information.*

Sign by entering your full name below along with today’s date*


Privacy policy

Kůra Růka is committed to the privacy of its clients. Personal information is treated as confidential and is used only for the purpose for which it was collected. Information kept on file will not be released to a third party without the express consent of the client or as required by law.

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since 2022