Confidential Client Intake Form
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1
2Confidential Client Intake Form
Client Name:
_
Male / Female
Date:
Address:
City:
State:
Zip:
Date of Birth _____________________
Married Y N
Anniversary date
/
/
Please check how you would like us to confirm your appointments. We Never Sell Your Info.
1.Home #
3.Cell #
_
SMS Text Confirmations through DemandForce
2.Work #
4.E-mail Address (
only for updates & confirmations
_
):
Occupation: _____________________
________________________________________________
How did you hear about Natural Elements Spa & Salon?
Newspaper __ Sign ___ Website___ Yellow pages____ Walk-in _____Other
___________
Spa Finder____ Gift Certificate ____ Friend/Relative ____ Best of Chesapeake ____ Google ______
Please circle all that apply
:
Are you currently seeing a Health care
Acute Pain
Doctor
Shortness in Breath
Professional? YES NO
Recommendation
If YES, for what reason?
Allergies
Heart Attack(s)
Skin Condition
Arthritis
High Blood
Swelling
Pressure
Chronic
Low Blood
Thyroid Problems
Are you taking any of the following
?
Injury
Pressure
__ Vitamins
__ Minerals __ Herbs
Circulatory
Migraines
Tingling/Numbness
__ Sedatives
__ Insulin
__ Diet Pills
Problems
in Limbs
__ Sleeping pills
__ Aspirin
__ Laxative
Depression
Osteoporosis
Tumor
__ Blood Thinner
__ Allergy Medication
Diabetes
Painful Joints
Other:
__ Antipsychotics
Antidepressants
Other Medications
Any recent (within 6 months) or past injuries/accident (serious)?
Are you pregnant
?
YES
NO If YES, how far a long?
Weeks (skin is more
sensitive during pregnancy so please communicate with your Spa Professional)
Have you ever had a reaction to any of the following
? Cosmetics Medicine Iodine Pollen
Hydroxyl Acids Animal Fragrance Essential oils
Sunscreens
Fruits Vegetables Nuts/seeds
Other______________
_
Are you on a diet, cleanse or fasting program at this time
? ___ YES ___NO
What type of massage pressure do you prefer
? Light
Medium
Firm
Deep
What is your favorite aspect of a massage/facial/spa service
? _________________________
To maximize your experience, please express what your goals are for this treatment.
Signature Required On Back
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