Spa Client Intake Form
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Person
Emergency Contact Phone Number
Relationship to the Patient
Medical / History Data
Do you have any of the following conditions?
Spinal Cord Issues
Are you wearing any eye contact lenses?
Are you pregnant, breastfeed, or nursing? (Female)
Are you smoking? If yes, how many packs a day?
Are you wearing any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
How do you manage stress? Please elaborate:
I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.
Signature of the Patient
Signature of Parent/Guardian
Should be Empty: