Spa Client Intake Form

Full Name

Date

Email Address

Phone Number

Date of Birth

Emergency Contact Name

Emergency Contact Phone

How did you hear about us? What are your main areas of concern or treatment goals? Do you have any allergies or sensitivities? Are you currently taking any medications? If yes, please list. Do you have any current or past medical conditions? Have you recently undergone any surgeries or medical treatments? Is there anything else we should be aware of to ensure your comfort and safety? Signature Date