Client Intake Form

Client Information

Your names

Your email

Mobile Number/Whatsapp

DOB

Wedding Anniversary

Emergency Contact Name

Emergency Contact Phone

Referral (optional)

Do you have any medical conditions we should be aware of?
If yes, please specify on the field above.

Are you currently taking any medications?
If yes, please specify on the field above.

Do you have any allergies?
If yes, please specify on the field above.

Have you had any surgeries in the last 6 months?
If yes, please specify on the field above.

Are you pregnant or breastfeeding?

If yes, please specify on the field above.

Do you have any skin conditions (e.g., eczema, psoriasis, sensitive skin)?
If yes, please specify on the field above.

1. What is your primary goal for today’s visit?
RelaxationSkin treatmentPain ReliefOther (Please specify)

2. Do you regularly receive spa treatments?
If yes, (How often?)

3. What is your daily skincare routine like?
MorningNight

1. Do you have any areas you would like us to focus on or avoid?
Focus/Avoid :

2. For massage, what level of pressure do you prefer?
LightMediumFirm

3. Do you have any fragrance preferences or sensitivities?
If yes, please specify on the field above.

Date Signed