L Spa - New Customer Intake Form

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Email:

Cell Phone:

Birthday:

How did you hear about us?

Are you pregnant?

If yes, How Far along?

Allergies?

If yes, please explain:

Any skin problems?

If yes, please explain:

Any recent surgeries?

If yes, please explain:

Have you broken any bones?

If yes, please explain:

Are you currently taking any medication? (Please include muscle relaxants and blood thinners)

If yes, please explain:

Check the conditions that apply to you:

Arthritis
Bone or Joint disease
Blood Clots
Cancer
Communicable Diseases (STD, TB, pinkeye, ect.)
Diabetes
Epileptic
Fibromyalgia
Headaches/Migraines
Heart Problems
Hepatitis___Type
High/low blood pressure
HIV/AIDS
Pacemaker/defibulator
Pins or metallic implants
Varicose Veins
Nail infection
Athletes foot
Stroke

Massage Therapy

Have you ever experienced a professional massage session?

Injuries/Accidents that are still affecting you:

List any spine or back injuries, include any disk problems, bulging, ruptured, herniated, and the location. Also include any treatments you are currently undergoing for these:

Please list the numbers from the the drawing of the areas where you are feeling discomfort:

I understand that massage therapy is not a replacement for medical care and that no diagnosis will be made. I will keep my therapist informed of any medical conditions to make sure there are no contraindications for massage. I know if I fail to do so my therapist is not liable for any problems arising from my massage. I also understand that any sexually suggested remarks or advances made by me will result in termination of my session. I understand that by signing this document I give my informed consent; and that consent can be withdrawn at any time.

I agree to these terms

Waxing

Have you ever waxed before?

Do you feel your skin is sensitive or allergic to any products?

If yes, please explain:

Are you taking or applying any medications that makes you sensitive to the sun? Acne medication, Retinols, or Accutane?

If yes, please list:

WAXING: I have answered all the questions to the best of my knowledge. I understand that, because of certain health conditions I may be refused waxing services. I also understand that there may be swelling, irritation, or slight skin lifting in the waxed areas. This is only a temporary condition. I agree to assume the risk of any injury or damage. I fully understand that signing this is a release of liability.

I agree to these terms

CANCELLATION POLICY: Because L-Spa services are reserved especially for you, as a courtesy to other clients and our staff we require a 24-hour cancellation policy. If you do not allow 24 hour notice you will be billed 50% of your scheduled appointment.

Every effort will be made to accommodate a late arrival though L-Spa may not be able to extend the time of your service. Scheduling is designed to allow the correct time needed to complete each service.

I agree to these terms

New Customer Intake Form

Massage Therapy

Waxing

CONTACT

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