Body Scrub
Client Intake Form
Name
*
First Name
Last Name
Contact
*
Phone Number
Email Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Employer / Occupation
Employer
Occupation
Emergency Contact
*
First Name
Phone Number
How did you hear about Sherrielee Holistic Skin Spa?
*
Have you ever had a Body Scrub before?
Yes
No
If you've had a Body Scrub before, when?
-
Month
-
Day
Year
Put today's date for No.
Do you have any recent sunburn, bruises, cuts or scrapes?
*
Yes
No
Are you Pregnant? (please note, I do not do pregnancy massages or body scrubs and I will have to refer you to a LMT. (Licensed Massage Therapist.)*
*
Yes
No
Please initial that you are not pregnant.
*
What result do you want from your treatment today? (please click all that apply)
Glowing Skin
Relax
Circulation
Reduce Anxiety
Improve Overall Sleep Quality
All of the above
Please check if you currently have any of these conditions. (please click all that apply)
*
Anxiety
Auto Immune Disorder
Arthritis
Back Problems
Diabetes
Hypertension
Hypotension
Jaw Pain (TMJ)
Kidney Disease
Migraines
Muscle Spasms
Neck Problems
Pace Maker
Osteoporosis
Recent Surgery
Respiratory Problems
Sleeping Disorders
Varicose Veins
No conditions, I love Body Scrubs!
If any concerns please describe:
Do you have any special skin problems or concerns pertaining to your face or body?
*
Yes
No
If any special skin problems or concerns pertaining to your face or body, please explain.
Any accidents, injuries or illnesses still effecting you?
*
Yes
No
If any accidents, injuries or illnesses still effecting you, please explain.
Client Signature
*
Body Scrub Treatments are considered safe, and it is my responsibility to inform Sherrielee Holistic Skin Spa if any changes in my health occur. I am responsible for informing Sherrielee Holistic Skin Spa of all health conditions, diseases or disorders from which I suffer. I understand that Body Scrub Treatments are not substitutes for medical treatment, and I still need to continue any medical treatment that I am receiving through my physician. I understand that the primary purpose of the treatment or treatments that I am about to receive is for relaxation, detoxification purposes, and skin cleansing and wellness benefits. I understand that I have the right to refuse treatment at any time, and I have the right to end my treatments at any time. I also understand that I have a right to ask whatever questions I have before, during, or after my treatments. I understand that results are not guaranteed. I understand the treatment or treatments that I am about to receive. I consent to Sherrielee Holistic Skin Spa and I agree to abide with all terms and conditions.
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