HE Intake Form

2175 Continental Dr. ~ West Bend, WI 53095 ~ -262-306-6691 ~ www.HeDaySpa.com Guest Intake Form

NAME

Todays Date

Date

ADDRESS

CITY

STATE

ZIP CODE

HOME Phone

CELLULAR

Cell Phone Carrier for Text confirmations

WORK

E MAIL

example@example.com

Would you like to be confirmed for services via:

TextEmailBoth

DATE OF BIRTH

Date

Sex

MaleFemale

OCCUPATION

EMERGENCY CONTACT NAME & RELATIONSHIP

PHONE NUMBER TO BE REACHED AT

HOW WERE YOU REFERRED TO OUR DAY SPA?

Have you ever had a massage?

YesNo

Have you ever had a facial?

YesNo

Have you ever had a body treatment?

YesNo

Are you here for Healing of your:

MindBodySpirit

ARE YOU CURRENTLY EXPERIENCING PAIN? Where?

CURRENT MEDICATIONS (TOPICAL & INTERNAL)

ALLERGIES OR SENSITIVIES

Allergic to nuts, nut oils or latex

SURGERIES

HAVE YOU HAD CANCER?

TYPE

Do you have any of the following:

Do you have a Pacemaker

YesNo

Do you smoke or vape?

YesNo

Do you wear contact lenses?

YesNo

Do you wear Hearing aids?

YesNo

Are you under the care of a Dermatologist

YesNo

DERMATOLOGISTS NAME

REASON FOR TREATMENT

What brand of soap do you use?

What brand of cleanser do you use?

What brand of scrub do you use?

What brand of moisturizer do you use?

What brand of masks do you use?

OTHER

HOW MUCH WATER DO YOU DRINK IN A DAY?

CAFFEINE?

Alcohol?

Other?

HOW WOULD YOU DESCRIBE YOUR DAILY LEVEL OF STRESS?

Do you exercise regularly?

YesNo

Are you Pregnant?

YesNo

IF YES, # OF WEEKS

Due Date

Are you under the care of a Doctor?

YesNo

Is your Doctor aware of you being here for services?

YesNo

Skin Conditions:

Sun Exposure History

Always burn, never tanSeldom Burn, tan easilyNever burn, tan easilyUsually burn, tan with difficulty

Approximate Sun Exposure:

MinimalOccasionalRecreationalOccupational

Do you use a tanning bed?

YesNo

If yes how often

Have you previously undergone:

Do you use SPF daily?

YesNo

If Yes what %

Please list any other information we may need to know about:

Have you recently had any symptoms of a cold

When was the last time you ate:

Consent Form for Treatment at Healing Elements Day Spa

By signing this consent form, I give permission to receive treatment from the certified and licensed professionals at Healing Elements Day Spa. I understand that the treatments provided are intended to enhance the well-being of my mind and body. I agree to communicate openly with my practitioner if at any time I feel that my well-being is compromised.

I acknowledge the risks associated with massage, skincare treatments, and body services, and I assume responsibility for my participation in these treatments. I understand that the service staff do not diagnose illnesses, diseases, or any physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals, or perform spinal thrust manipulations. I recognize that massage is not a substitute for medical examination or diagnosis, and I am encouraged to consult my primary healthcare provider for such services.

I have disclosed all medical conditions that I am aware of and will inform my service professional of any changes in my health status.

Please Note:

Healing Elements Day Spa cannot guarantee confirmations for your scheduled services. We recommend that you personally note or record your appointment times.
Prices are subject to change at any time without prior notice.
Cancellation Policy:

A 24-hour cancellation notice is required for any single service.
A 48-hour cancellation notice is required for weekend appointments, multiple services, or groups of two or more.
All weekend appointments require 48 hours’ notice for cancellation.

If adequate notice is not provided, I understand that I will be charged for the scheduled service.

SIGNATURE*

DATE

Date

Print

PARENT OR GUARDIAN FOR THOSE 17 AND UNDER

DATE

Date

FOR WOMEN:

PEELS, CIRCLE TYPE: LACTIC ACID GLYCOLIC ACID

CONSENT TO TREAT: