Copal Wellness | Massage & Aesthetics Practice Fort Worth, TX
By Intention. By Appointment Only. | Beauty | Body | Wellness
Full Legal Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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Month
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Day
Year
Date
Service Requested
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Relaxation Massage
Clinical Pain + Recovery Massage
Post-Op recovery Management
Clinical Skin Care
Body Conouring Refinement
Other
Emergency Contact Name
Preferred Method of Contact
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Text
Call
Email
Preferred Appointment Date
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-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Which spa services are you interested in?
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Massage Therapy
Facial Treatments
Body Treatments
Aromatherapy
Other
Do you have any allergies or medical conditions we should be aware of?
Additional Notes or Preferences
Please sign below to confirm the information provided is accurate.
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Health Questions
check current symptoms/ concerns that apply
Health Questions (Check All That Apply)
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Pain
Swelling
Skin Concerns
Tightness / Restricted Movement
Anxiety / Stress
Sleep Issues
Other
Surgical Medical History (If Available)
Have you had any recent surgery?
If yes, please specify type and date.
Do you currently have a physician or surgeon overseeing your recovery?
Any cosmetic procedures in the last 12 months?
Any chronic condition? (Optional)
Body Work History
For Therapeutic Relaxation Bodywork or Medical Pain Management Massage
Preferred Pressure
Please Select
Light - No Pain - Therapeutic Relaxation Massage
Medium - Medical Massage
Have you ever received Lymphatic Drainage?
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Yes
No
I'm Interested in Learning More
Have you ever had post-op massage care?
Please Select
Yes
No
I Want to Learn More
I Want to Start Services
Any Past Negative Reaction to Massage / Bodywork?
Why Are You Seeking Care at Copal Wellness Today? What Are Your Goals?
Atmosphere & Experience
Average Stress Level
Please Select
1-3
3-5
5-7
7-10
Preferred Treatment Ambiance
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Quiet and Minimal Conversation
Light Check-Ins Only
Comfortable Conversation Welcomed
Completely Silent
Music Preference
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Ambient Spa
Instrumental
Nature Sounds
No Music
Blues
Additional Notes: Is there anything else you'd like me to know to ensure your experience is exceptional?
Client Acknowledgment
I understand Copal Wellness provides professional, licensed bodywork, massage, skincare, and aesthetic services in a private, non-sexual, and respectful environment. I agree to communicate preferences clearly and understand that services may be modified for safety and wellbeing.
Wellness Assessment
Hydration Level
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Please Select
Low
Moderate
High
Activity Level
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Please Select
Sedentary
Moderate
High
Gym, Running, Cycling, etc.
High Work Related
Construction, Hairstylist, Nurse, etc.
Goals for Care at Copal Wellness
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What Does "Feeling Better" Look Like For You?
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Consent & Understanding
Consent & Understanding
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I understand services are non-medical wellness, holistic skincare, aesthetic & massage therapy services.
I consent to treatment.
I understand results vary and multiple sessions may be recommended for optimal outcomes.
I agree to communicate any discomfort during my sessions.
I understand I should always follow my physician's advice, and Copal Wellness does not treat, diagnose, or prescribe and is not a medical professional and does not take the place of my medical professional in any way.
I understand I should follow my physician's Post-Op instructions first, if applicable.
I understand and agree to the No Refund & Cancellation Policy.
Photo Documentation Consent
Photo Documentation Consent
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Please Select
I consent to before/after progress photos for internal tracking and care planning and for social media, website, and other advertising only.
I do not consent.
Client Signature
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Date
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Month
-
Day
Year
Date
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