Client Intake Form printable pdf download

CLIENT INTAKE FORM !

WELCOME! I would like to make your appointment as pleasant and comfortable as possible. If at any

time you have questions regarding your session, please let me know.

Name ____________________________________

Date of Birth_______________________

Address _____________________________________________________________________

City ____________________________________ State ______ Zip Code ________________

Home Phone _______________ Cell Phone ________________ Work Phone ______________

Email _______________________________________________________________________

Occupation __________________________________________________________________

How did you hear about Crystal in Sedona? ___________________________________________

Have you ever experienced any of the following:

Massage Therapy, Bodywork, Energy Work, a Scrub, a Wrap, or a Luxury Soak?

If yes to any of the above please note exact modalities (example: Aromatherapy Massage, Hot Stone

Massage, Sugar Scrub, Lavender Wrap.) _______________________________________________

____________________________________________________________________________

Are you currently taking any medications? Yes ____ No ____

If yes, please list name and reason for medications _______________________________________

____________________________________________________________________________

Are you currently seeing a healthcare professional? Yes ____ No ____

If yes, please list names and reason/treatment __________________________________________

____________________________________________________________________________

Client Intake Form