CLIENT INTAKE FORM
Name
First Name
Last Name
How did you hear about us? Through a referral, online search, Yelp or other?
What service(s)are you interested in? Consultation, body sculpting, massage therapy, teeth whitening or wellness products?
Do you have any chronic medical conditions? If so, please list them:
Do you have any allergies to latex, medications, herbal or natural supplements? If so, please list them:
Do you have any hearing aids or implanted medical devices (i.e. pacemaker)?
Do you have or have you had cancer within the last 12 months? If so, are you currently undergoing chemotherapy treatment?
Please check all that apply:
thyroid issues
high blood pressure
epilepsy
history of infections
autoimmune disease
skin disease
neck or back issues
Are you currently pregnant or nursing?
Appointment
Choose Your Massage
Chair Massage
Couples Massage
Deep Tissue
Reflexology
Shiatsu Stretching
Sports Massage
Swedish Relaxation
Other:
Mark Areas Of Concern
Please verify that you are human
*
Deposit
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Deposit
Non refundable $25 deposit required, goes toward balance
$
25.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Thank you!
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