Postpartum Spa Intake Form
Complete this intake form to help us prepare for your postpartum spa appointment and tailor your service experience.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Pronouns
She/Her
He/Him
They/Them
Prefer not to say
Self-describe
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Postpartum Spa Intake Details
Baby Birth Date or Postpartum Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How Many Weeks Postpartum Are You?
*
Are You Currently Breastfeeding or Pumping?
Breastfeeding
Pumping
Both
Neither
Prefer not to say
Comfort Notes or Areas to Avoid
Service Request
Preferred Service(s) or Treatment Focus
*
Postpartum Massage
Lactation Support Session
Belly Binding
Scar Care Focus
Relaxation/Stress Relief
Pelvic Floor Support
Other
Desired Appointment Date and Time
*
Scheduling Notes or Accessibility Preferences
Submit
Should be Empty: