Intake Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Date

How did you hear about us?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Preferred Massage Pressure?

What are your specific concerns at this time regarding your skin or body?

What is your stress level right now?

LowAverageSomewhat StressedVery Stressed

Please list Injuries or surgeries:

Have you ever received professional skin care treatments or massage?

What do you consider your skin type? (For facials only)

What is your daily skin care regimen? (For Facials Only)

What is your goal for this session.

Please check all that apply.*

Signature*

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 Blomkraft 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.