Intake Form

We're delighted to embark on this wellness journey with you. To ensure your experience is tailored to your needs and preferences, we please ask you to complete this intake form prior to your appointment.

Client Information

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Info

Emergency Contact Name

First Name

Last Name

Relationship

Emergency Contact Phone Number

(###)

###

####

Health History

Have you had any recent surgeries or medical procedures?

If yes, please specify:

Are you currently under the care of a physician or receiving any medical treatment?

If yes, please provide details:

Do you have any allergies (food, medication, etc.)?

If yes, please list:

Are you currently taking any medications?

If yes, please list:

Do you have any existing medical conditions ?

If yes, please specify:

Are you pregnant?

If yes, how many weeks along are you?

Do you experience any chronic pain or discomfort?

If yes, please describe:

Have you ever experienced any adverse reactions to spa treatments?

If yes, please provide details:

Lifestyle and Preferences

How would you rate your stress level on a scale of 1 to 10?

(1 being low, 10 being high)

What are your main wellness goals for this spa visit?

Are there any areas of your body you would like the therapist to focus on during your treatment?

Do you have any preferences regarding pressure?

(e.g., light, medium, firm)

Is there anything else you would like your therapist to know before your treatment?

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge and I consent to that information being used to create a personalized treatment plan.

A massage or treatment table with a white sheet in a room with beige walls, a round mirror, a wooden desk, a wall-mounted robe, and a brown upholstered chair.

Intake Form

Client Information

Emergency Contact Info

Health History

Lifestyle and Preferences

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