Spa Intake Form

Want to save time at check in? Please take a moment to fill out our intake form online.
Be sure to have each individual having services with us fill out a seperate form and submit it.

SPA INTAKE FORM

* Indicates required field

Name *

First

Last

Cell Phone *

Email *

If you would like to be added to our newsletter.

DATE AND TIME OF YOUR CURRENT APPOINTMENT *

Is this your first massage? *

Yes No

Do you have a pressure preference for your service today? *

Light Medium Firm

Are you currently under the care of a physician? If so please explain *

PLEASE LIST ANY ALLERGIES WE SHOULD BE AWARE OF *

Do you have any of the following conditions? *

Pregnant or Nursing Heart Condition Vericose Veins Diabetes Metal plates or pins Epilepsy None Applicable

Some services are contraindicated for certain conditions. We need to know ahead of time if we will need to adjust or change your treatment protocol

Are you currently on any of the following medications: *

Muscle Relaxants Pain Medication Antihypertensives Diuretics Blood Thinners None Applicable

PLEASE LIST ANY PAIN, INJURIES OR AREAS OF FOCUS YOU WOULD LIKE ADDRESSED DURING YOUR MASSAGE TODAY *

IF YOU ARE HAVING A FACIAL OR BODY TREATMENT WITH US PLEASE ALSO FILL OUT THE FOLLOWING INFORMATION:

HAVE YOU EVER HAD A FACIAL BEFORE? *

YES NO

DO YOU HAVE ANY SPECIFIC TREATMENT GOALS? *

ARE YOU UNDER THE CARE OF A DERMATOLOGIST? IF SO PLEASE EXPLAIN *

DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS: *

Rosacea Psoriasis Eczema

are you currently taking any of the following medications? *

Retin-A Accutane Differin Hydroquinone Renova

Submit

AUGUST MOON SPA... WHERE RELAXATION BEGINS

CONTACT & LOCATION SITEMAP

AUGUST MOON SPA AT LA TOURELLE
1150 Danby Road (96B) • Ithaca, NY 14850
(607) 256-2772

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