Body Contouring
Consultation Form
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email Address
example@example.com
Emergency Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Is this your first time for a spa massage?
Yes
No
Do you have any of the following conditions?
Allergies
Asthma
Back problems
Nerve damage
Diabetes
Cancer
High/low blood pressure
Epilepsy
Recent Surgery/Injury
Heart Condition
Poor Circulation
Other
Check the following if any of them applies for you.
Pregnancy
Breast feeding
Pain in any area
Headaches/Migraines
Numbness
Sensitive Skin
Other
Are you under any medication?
*
Yes
No
Please give details.
Select your skin type and concerns:
*
Normal
Dry
Balanced
Oily
High color
Sensitive
Sun damage
Wrinkles
Dark circles
Other
Date
-
Month
-
Day
Year
Date
Client's Signature
Therapist Name
First Name
Last Name
Therapist's Signature
Submit
Submit
Should be Empty: