Client Intake Form for Nature Spa

Welcome to Nature Spa!

We are dedicated to providing you with a relaxing and rejuvenating experience. To ensure your safety and tailor our services to your specific needs, please complete this form thoroughly. All information provided will be kept confidential.

Client Information

First Name

Last Name

Date of Birth

Phone Number

Email Address

Street Address

City/Suburb

State/Province

Postal/Zip Code

Emergency Contact Name

Phone Number

Health History

Please answer the following questions honestly and completely.

Are you currently pregnant or breastfeeding?

Yes

No

If yes, please specify trimester or age of infant.

Do you have any known allergies (e.g., skin, food, medications)?

Yes

No

If yes, please list.

Are you currently taking any medications (prescription or over-the-counter)?

Yes

No

If yes, please list.

Have you had any recent cosmetic procedures (e.g., Botox, fillers, chemical peels)?

Yes

No

If yes, when?

Please specify.

Do you have any sensitivities to essential oils or fragrances?

Yes

No

If yes, please specify.

Do you have any open wounds, cuts, or abrasions?

Yes

No

If yes, please specify location.

Do you experience any chronic pain?

Yes

No

If yes, please specify location and intensity.

Service Selection & Preferences

Please indicate which services you are interested in and any specific preferences.

Preferred Pressure

Light

Medium

Firm

Areas of Focus/Avoidance.

Specific Skin Concerns

Body Treatments:

Body Scrub (Exfoliation)

Body Wrap (Hydration & Detox)

Herbal Bath (Relaxation & Detox)

Salt Glow (Exfoliation and Mineral Infusion)

Specific Preferences:

Nail Services:

Manicure (Classic, Gel, Paraffin)

Pedicure (Classic, Gel, Paraffin)

Nail Enhancements (Acrylic, Gel Extensions)

Specific Preferences:

Additional Information/Requests

Are there any specific areas you would like us to focus on?

Are there any areas you would like us to avoid?

What are your goals for today's spa visit? (e.g., relaxation, pain relief, skin improvement)

How did you hear about Nature Spa?

Client Consent

I understand that the information I have provided is accurate to the best of my knowledge.

I consent to receive the spa services indicated above, and I understand that it is my responsibility to inform the spa staff of any changes in my health or medical conditions.

I release Nature Spa and its staff from any liability related to the services provided, provided they are performed with reasonable care and skill.

Client Signature

Important Notes:

This form is intended to gather initial information and does not constitute a diagnosis.
The information provided will be used to determine the most appropriate services for the client.
The Nature Spa and its staff will discuss the client's needs and goals in more detail during the initial consultation.
It is crucial to adapt this form to comply with all local and national privacy laws.
This form is a template, and may need to be adjusted to suit the specific needs of your practice.