Intake Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Health History: Do you have any existing medical conditions (e.g., high blood pressure, diabetes, heart condition, autoimmune disease, etc.) Any recent surgeries or injuries I need to be made aware of? Any allergies or sensitivities to any products/ingredients? Any medications I need to know about?

Are you experiencing any current physical or emotional stressors? If comfortable, please explain.

Expectations and Preferences: What specific results or goals are you hoping to achieve from your scheduled service? Do you have any preferences regarding the type of products used, smells, the intensity of pressure, or temperature (table, towels, etc.)?

Lifestyle and Habits: How much water do you typically consume daily? Do you smoke or are you exposed to secondhand smoke? How is your daily sun exposure? Do you engage in regular physical activity or exercise? Do you have a physically demanding job or sedentary lifestyle?

Pregnancy: Are you pregnant? If yes, how far along are you?

Emergency Contact: Provide the name and phone number of someone to be reached in case of an emergency during the session.

How did you hear about me? (e.g., friends/family, Instagram, Facebook, Google, TikTok, other)

YesNoOpen to the idea

Please fill out the next four questions if you are scheduled for a full body massage.

Have you had a massage before? If yes, how often?

Pain or Discomfort: Any specific areas of pain, tension, or discomfort? Do you have any specific areas you would like the massage therapist to focus on or avoid?

Any preferences regarding massage techniques (e.g., Swedish, Reiki, Stretching, Lomi Lomi, etc.)?

Goals for the Massage: What are you hoping to achieve through the massage session? (e.g., relaxation, pain relief, stress reduction).

Please fill out the next three questions if you are scheduled for a facial.

Skin History: Describe any current skin concerns (e.g., acne, dryness, sensitivity, aging). Do you have any history of skin conditions (e.g., eczema, psoriasis)?

Describe you skincare routine, including products used and frequency. Are there any specific products or ingredients that your skin reacts to?

Do you get filler injections? If so, where do you get it in your face and how long ago was your last injection?

I hereby provide my informed consent to receive services from Bre Essence LLC, including head spa services, massage therapy, facial treatments and sound healing. I understand that these services aim to promote relaxation and well-being while addressing specific concerns such as scalp health, muscular tension, and skin appearance.

I acknowledge that it is my responsibility to disclose any medications, allergies, or health changes that may affect the treatments' outcomes. Certain medications may have an impact on scalp/skin conditions or may interact with specific spa products. It is important that I disclose this information to ensure the safety and effectiveness of the service.

I also have the right to communicate openly with the staff regarding my comfort level, any discomfort or adjustments needed during the service, including pressure, areas of focus, draping, or temperature.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and the service will be paid in full.

I acknowledge the inherent risks associated with each treatment, such as, but not limited to, allergic reactions or skin irritations, soreness, and/or bruising and release Bre Essence LLC, its staff, and professionals from any liability for adverse reactions. I have read and understand the terms of this consent paragraph. By submitting this form, I willingly consent to the services provided by Bre Essence LLC.

Describe your hair care routine: Do you frequently use heat styling tools? How often do wash your hair? Do you use dry shampoo? What hair care products do you currently use? Etc.

Do you have any existing scalp conditions (e.g., dandruff, psoriasis, eczema). Describe any current issues with your hair or scalp (e.g., dryness, oiliness, itching).