Lotus SPA online intake form

Intake Form

Massage and SPA Services
Name*

First NameLast Name
Age
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
How would you rate your general health?*

ExcellentGoodFairPoor
Have you had a professional massage before?

YesNo
Reason for initial visit*
Additional information you would like to provide
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage, sauna or other services I voluntarily may receive and give my consent for those. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.
Signature*

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Date*

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Date
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Intake Form