Website BodiScience New Client Intake Form

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BodiScience Client Intake Form

All information is held in the strictest confidence. At no point is information disclosed or shared without your written consent.

If you need to contact us, please call 978.927.9909. We are in Suite 101D (by Marblehead Bank) in the front of 100 Cummings Center Beverly, MA. Enter from the outside thru door 100E, and take an immediate right into our spa.
Full Name*

First NameMiddle NameLast Name
Preferred Name

Name you prefer to be called
What Pronouns Do You Use?

she/herhe/himthey/themOther
Address*

Street Address

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CityState / Province

Postal / Zip CodeCountry
Birth Date*

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E-mail*
Phone Number*
This is my:*
Occupation
How did you hear about BodiScience Wellness Center & Spa?
Please check any of these that you have experienced:

Hearing LossAsthmaTeeth and gumsMigraine headachesVaricose VeinsLow blood pressureHigh blood pressureAnemiaUlcerDiabetesHeart DiseaseHeart AttackCancerInsomniaColitisArthritisStrokeSurgeryPTSDAnxietyDepressionOther
1. Have you had skincare treatments before? If yes, please name the salon/spa?
2. Have you seen a dermatologist in the last 5 years and reason for treatment?
3. Have you had cosmetic surgery in the past year and what type?
4. Have you had a major illness and/or operation in the past year? If yes, please provide type and approximate date.
5. What is your stress level?

LightModerateHighRecent TraumaOther
6. Do you smoke?

YesNoIf yes, how muchOther
7. Please list all allergies*

LatexMetalsFoodShellfishOther
8. What is your level of alcohol consumption?

LightModerateHeavyNeverOther
9. Do you exercise?

NoIf yes, how oftenOther
10. Do you wear contact lenses?

YesNoOther
11. Do you meditate?

NoYesOther
12. Please list all medications and vitamins you are currently taking*
13. Please share your expectations of the service you are receiving today?
14. Have you received a massage before?

YesNo
15. If yes, were you pleased with the results and where did you receive your last treatment?
16. Are you currently seeing any other healthcare professional or health/wellness coach? Please share name.
17. IMPORTANT: Is there anything else regarding your health or your expectations for your visit with us that we have not asked?
19. Please check any interests you have:

YogaSuncareAyurvedaNail CareNutritionFoot CareBody careWaxingBreast CareDetoxVitaminsMeditationWellnessSeasonal SkincareSeries of TreatmentsEmotional HealthOther
BodiScienceWellness Center & Spa Policies:
- We have a 48-hour cancellation polioy. If you cancel or reschedule your appointment within that time frame, you will be charged a cancellation fee. We kindly ask that our guests understand and respect this policy for our small business.
- Client services and chart information are confidential. Written authorization is required from you to release any information.
- Please turn off your cell phone (sound and vibration) while in the spa for optimal relaxation and consideration of all.
- Should your treatment require, after your therapist has left the room, you may disrobe to your comfort level; you will be draped during your treatment for your privacy.
- You will have a brief introductory conversation with your BodiScience Practitioner before your treatment begins.
- I understand that my BodiScience Practitioner may end the session at any time for any reason.
- Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.
Client Agreement:

I understand that BodiScience Practitioners do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that BodiScience treatments are not a substitute for medical examination or diagnosis, and it is recommended that a physician is seen for that service.

It is my choice to receive a treatment as a complementary therapy.

I understand that the treatment I selected is designed to address skin and/or body care.

I understand that if I feel pain or discomfort at any time during the session, I will immediately inform my practitioner so that they may adjust.

I have stated my pertinent medical conditions and will update the BodiScience Practitioner of any changes in my health status or medications.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless BodiScience Wellness Center & Spa and the BodiScience Practioner from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the BodiScience policy and client agreement above
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