Spa Client Intake Form
Patient Data
Patient Name
First Name
Last Name
Age
Occupation
Gender
Please Select
Male
Female
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Relationship to the Patient
Medical / History Data
Do you have any of the following conditions?
Hypertension
Heart issues
Rashes
Diabetes
Bone problems
Blood Clooting
Spams/Cramps
Sprains
Varicose Veins
Arthritis
Seizure
Spinal Cord Issues
Hormonal changes
Communicable Disease
Claustrophobia
Taking Accutane
Showing any signs or symptoms of Covid 19 including sore throat, dry cough, temperature.
Are you wearing any eye contact lenses?
Yes
No
Are you pregnant, breastfeed, or nursing? (Female)
Yes
No
Do you have any skin rashes or irritation?
Yes
NO
If yes, please describe skin irriations-
Are you smoking? If yes, how many packs a day?
Are you wearing any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
Do you have any known allergies to foods or medications:
What Skin Care products are tools are you currently using:
Are you interested in at home suggestions and follow up care recommendations?
Authorization
I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.
Signature of the Patient
Parent/Guardian Name
First Name
Last Name
Signature of Parent/Guardian
Submit
Print Form
Should be Empty: