Client Information And Consultation Form printable pdf download

Client Information And Consultation Form

Client Information and Consultation Form

Name:_________________________________________________ Today’s Date:_______________

Last

First

MM/DD/YY

Address:_________________________________________________________________________

Street

Apt.#

City

Zip

Phone:_______________________ Home / Work / Cell ____________________ Home / Work / Cell

Email: ___________________________________________________________________________

May we send you our email newsletter? YES NO

Occupation:___________________________________________

Date of Birth:______________ Emergency Contact:_______________________________________

Name

Phone #

Reason for Appointment:____________________________________________________________

How did you hear about us? Haven Spa Website

Yelp Referred by____________________

*If a friend referred you, please let us know who they are so we may thank them with our referral bonus!*

Have you had a professional massage before? YES NO

If yes, how long ago?_____________

Do you have any of the following medical concerns or considerations?

SKIN PROBLEMS

ARTHRITIS

VARICOSE VEINS

BLOOD CLOTS

DIABETES

CIRCULATION DISORDERS

SEIZURES

HIGH or LOW BLOOD PRESSURE

CONTAGIOUS DISEASE

Are you currently taking any medications? YES

If yes, for what conditions?______________________________________________________

Do you have any allergies or sensitivities to lotions or oils? YES

If yes, please list:_____________________________________________________________

Could you be pregnant? YES

If yes, how far along are you?________________________

In the past 2 years have you had any major Illness, Injury, or Surgery? YES

If so, what illness, injury, or surgery did you have? ___________________________________

Have you been treated for cancer? YES

If yes, please complete the following. If no, continue to the back.

What type?_____________________ Treatment plan?_________________________

Any lymph nodes removed? YES

If yes, where?________________________

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Client Information And Consultation Form

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