Client Intake Form Our goal is to deliver the most pleasurable spa experiences… in order to customize your experience and assure your satisfaction and safety please complete the questions below. Step 1 of 3 33% Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* Preferred Method of Contact Phone Email Mail Fax BirthdateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reserved Treatment Selection Facial Hair, Make-Up Manicure Body Treatments Pedicure Waxing Spray Tan Private Yoga For FaceSkin TypeSelect one...MatureSensitiveDryOilyVery Sensitive/RosaceaCombinationAcne/ ProblematicWhat are your skin concerns? Sun Damage Hyperpigmentation Acne/ Problematic Scars Rosacea Dehydration Loss of Elasticity Blackheads Enlarged Pores Sensitivity Uneven Skin Texture Whiteheads Dilated Capillaries For BodyWhat are some of your concerns? Muscle Tension Dry skin Sunburned Stress Oily skin Arthritis Discomfort Cellulite Loss of Elasticity & Firmness Dehydration Circulation Desired Massage PressureSelect one...LightMediumFirmDeep TissueFor Hands & FeetOther Concerns Age Spots Ingrown Nails Dry Skin Fragile Nails Dry Cuticles Brittle Nails Callous Splitting Nails Are you currently using a Retin A /Alpha Hydroxy Acids? Yes No Is there anything else we should know that may a ect your treatment? Additional InformationIt is not advisable to engage in certain treatments where speci c medical conditions exist.Please advise your therapist if you have personal history of: Heart Disease Low / High Blood Pressure Diabetes None of the above Migraines/Headaches Thrombosis Allergies Cancer Recent Surgery Claustrophobia Arthritis Skin Irritations Asthma Any Present Injury Yes No Describe Injury Woman: Are you pregnant? Yes No RecommendationsIf you su er from heart condition, low or high blood pressure, heart arrhythmias or diabetes, please refrain from using sauna, steam and gym. Liability waiver. I declare that I am with full legal capacity and physical condition to utilize the spa facilities and I do it with full knowledge, understanding and appreciation of risks implicated therein. I hereby acknowledge and agree to use the facilities and/or treatments of the SPA with the understanding that the possible risks and/or injuries and/or diseases which I may sustain personally will be my full and complete responsibility. Through this writing, I release The Spa as well as all its employees.Signature in box belowCommentsThis field is for validation purposes and should be left unchanged.