Facial Intake Form

Facial Intake Form

Facial Intake form for spa. Form Preview
Facial Intake Form
Facial Intake Form
Hi there, please fill out and submit this intake form.
  • 1
    First Name
    Last Name
    Press
    Enter
  • 2
    Street Address
    Street Address Line 2
    City
    State / Province
    Postal / Zip Code
    Press
    Enter
  • 3
    example@example.com
    Press
    Enter
  • 4
    Area Code
    Phone Number
    Press
    Enter
  • 5
    Date
    Month
    Day
    Year
    Date
    Press
    Enter
  • 6
    Dat of Birth
    Date
    Month
    Day
    Year
    Date
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Press
    Enter
  • 11
    • Yes
    • No
    Press
    Enter
  • 12
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Press
    Enter
  • 18
    Press
    Enter
  • 19

    By SUBMITTING THIS FORM, you agree to the following:
    1) I give my permission to receive massage, facials or waxing services.
    2) I understand that therapeutic massage is not a substitute for traditional medical
    treatment or medications.
    3) I understand that the therapist or esthetician does not diagnose illnesses or injuries,
    or prescribe medications.
    4) I have clearance from my physician to receive facials and massage therapy.
    5) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
    • Superficial bruising or redness
    • Short-term muscle soreness
    • Exacerbation of undiscovered injury

    I, therefore, release Touch For Life Wellness and the individual therapist or esthetician from all liability concerning these injuries that may occur during the massage session.
    6) I understand the importance of informing my therapist of all medical
    conditions and medications I am taking, and to let the massage therapist know
    about any changes to these. I understand that there may be additional risks
    based on my physical condition.
    7) I understand that it is my responsibility to inform my therapist or esthetician of any
    discomfort I may feel during the session so he/she may adjust
    accordingly.
    8) I understand that I or the therapist may terminate the session at any
    time.
    9) I have been given a chance to ask questions about the session
    and my questions have been answered.

    Press
    Enter
  • 20
    Clear
    Press
    Enter
  • 21
    Because Touch For LIfe Wellness is by appointment only, your appointment is time reserved exclusively for you and we request that you please review our cancellation policy.
    Press
    Enter
  • Should be Empty:
Now create your own JotForm - It's free!Create your own JotForm
Question Label
1 of 21See AllGo Back