BodiScience Reservation Intake for Parties 3 and more

BodiScience New On-Line Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without your written consent. You may choose to skip answering any questions you feel impinges on personal information that you do not wish to disclose at this time.

Becoming a client of BodiScience, we will base our recommendations from the information you share with us, we cannot be responsible for individual results without in-depth information. Please be as forthcoming as possible so that we may assist you in the caring and professional manner that we have come to be known for.

Birthdate is an important piece for us to complete our assesment along with all your answers below.
Full Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
E-mail*
Phone Number*
This is my:*
Occupation
How did you hear about BodiScience Wellness Center & Spa?
Allergies
Medications
Please check any of these that you have experienced:

AsthmaTeeth and gumsTeeth & GumsMigraine headachesVaricose VeinsLow blood pressureHigh blood pressureAnemiaUlcerDiabetesHeart DiseaseHeart AttackCancerInsomniaColitisArthritisStrokeSurgeryOther
1. Have you had skincare treatments before and name of salon/spa?
2. Have you seen a dermatologist in the last 5 years and reason for treatment
3. Have you had cosmetic surgery in the past year and what type?
4. Have you had a major illness or operation in the past year? If yes, please provide type and approximate date .
5. What is your stress level

HighModerateLightRecent TraumaOther
6. Do you smoke

YesNoIf yes, how muchOther
7. Do you have any allergies*

LatexMetalsFoodShellfishOther
8. Are you currently taking any medication?*

Blood thinnersAccutaneMultivitaminThyroidOther
9. Alcohol Consumption

LightModerateHeavyNeverOther
10. Do you exercise

NoIf yes, how oftenOther
11. Do you wear contact lenses

YesNoOther
12. Do you take time to meditate

NoYesOther
13. List medications and vitamins*
14. What are your expectations of the treatment you are booking?
15. Have you received skincare treatments?

YesNo
16. If yes, were you pleased with the results and where did you receive your last treatment?
18. Is there anything you may wish to share with us that we have not asked?
17. Are you currently seeing any other healthcare professional or health/wellness coach? Share Name and or reason(s).
19. Please check off any interest you may have

YogaSuncareAyurvedaNail CareNutritionMake-upFoot CareBody careWaxingBreast CareBaby CareDetoxVitaminsMeditationWellnessSeasonal SkincareSeries of TreatmentsOther
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Enter the message as it's shown*
Credit Card Number for us to process for remaining balance of services on day of services - we will process through a "Self-Pay Checkout" system as to make sure your visit is as seamless as possible.
Credit card Number with Expiration Date

Deposit

Reservation Fee for Parties of 3 $100.00

Reservation Fee

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: