Client Intake Form - Massage
  • Client Intake Form - Massage and Facial
    		  
  • Date of Birth (tilt phone, leave blank, or fill on other device is DOB field is causing issue)
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  • Medical Information - Massage
     
  • Have you ever had a massage before?
  • Musculo-Skeletal

  • Circulatory and Respiratory

  • Skin

  • Digestive

  • Nervous System

  • Reproductive System

  • Are you currently pregnant or nursing?
  • Other

  • Are there any parts of your body that you do NOT wish to be worked?

  • SKIN CARE PORTION AND FORM SUBMISSION BUTTON ON NEXT PAGE

  • Medical Information - Skin Care
     
  • Are you using or have you used any of the following?

  • Have you ever reacted to any skincare products?
  • Have you seen a dermatologist in the past year?
  • Have you ever had a facial treatment before?
  • How is your skin during the day?

  • When you sunbathe or get accidental sun, how does your skin respond?
  • Have you ever had any of the following?
  • What areas of concern do you have? (Check all that apply):

  • Eyes:
  • Lips:
  • What skin care products are you currently using? (List brand where known)
  • Have you recently used any self-tanning products or received spray tan treatments?
  • Have you used any of the following hair removal methods in the past 6 weeks?
  • Have you had face or body waxing in the past week?
  • Have you used a tanning bed or been sun tanning in the past 2 weeks?

  • IF THIS IS YOUR FIRST TIME AT OUR SPA, PLEASE RETURN TO YOUR EMAIL TO ALSO COMPLETE THE GENERAL LIABILITY WAIVER ONCE YOUR CLIENT INTAKE HAS BEEN SUBMITTED.

  • Should be Empty: