Lava Massage and Skin Care, Client Intake Form
Personal info, health history, informed consent, release of liability.
Email address *
First Name *
Your answer
Last Name *
Your answer
Cell Phone Number (So you can receive text reminders for your appointments.) *
Your answer
Home Address *
Your answer
Date of Birth (Under age 18 requires in-person parental consent.) *
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YYYY
Occupation (Briefly describe... computer desk, standing, bending/lifting, etc.) *
Your answer
Were you referred by one of our current clients? If so, please give their name so we can send them a thank you.
Your answer
Have you ever had a professional massage or facial before? If so, how often, and when was your last treatment? *
Your answer
What are your goals or areas of concern for your upcoming appointment? *
Your answer
If you are getting a facial or skin treatment, please describe your usual skin care routine and what products you use:
Your answer
Have you ever had a chemical peel, microdermabrasion, dermaplaning, Botox, or collagen injections? If so, please describe and give date of last treatment:
Your answer
Are you currently experiencing any of the following today? *
Required
Do you exercise regularly? (Briefly describe.)
Your answer
Any skin sensitivities?
Are you currently pregnant? *
Required
Please list ALL ALLERGIES: (Type "NONE" if you have no allergies.) Some products used may contain nuts, soy, or shellfish. *
Your answer
Have you recently had any injuries, car accident, surgery, illness, etc? If yes, please describe:
Your answer
Do you suffer from chronic pain? If yes, please describe and give duration and location:
Your answer
Please list ALL current medications:
Your answer
Check all conditions or symptoms you currently have or recently had: *
Required
Please list any other health conditions we should be aware of:
Your answer
Please read the following and then check the box noting that you've read, understand, and agree: Lava Massage and Skin Care only employs licensed professionals and does not tolerate any sexually suggestive remarks or advances toward its employees/contractors. Any inappropriate comments or behavior will result in immediate termination of the treatment session and the client will be responsible for payment, in full. We reserve the right to refuse service to anyone at any time. *
Required
Please read the following and then check the appropriate box noting that you've read, understand, and agree: As the client, you are required to notify Lava Massage and Skin Care if you are unable to make it to your appointment as soon as possible, and at least 24 hours in advance. All clients are required to provide a valid credit card at time of booking, with the understanding that any same-day cancellations or no-shows will result in a cancellation fee in the amount of 50% of scheduled service price. This cancellation fee will be automatically charged to your credit card on file. If no credit card is available, the fee will be deducted from any prepaid packages or gift cards on file. Exceptions for special circumstances may be made on an individual basis, and can be requested by speaking to management. Decisions made by the manager and owner of Lava Massage and Skin Care are final. Clients failing to pay any owed cancellation fees will be prohibited from booking future appointments and will be refused service. This policy allows us to pay our employees/contractors for their time and ensures that we can continue to offer outstanding service at affordable, competitive prices, and provide same-day appointments when needed. *
Required
Please read the following and then check the box noting that you've read, understand, and agree: As the client, it is your responsibility to inform your therapist or esthetician of any pre-existing conditions. If you feel any discomfort during your session, please inform your therapist or esthetician immediately so that they can adjust the treatment. By checking the box and signing below, you agree to accept all risks associated with your treatment. Lava Massage and Skin Care and its employees/contractors are not responsible for any injury or damage resulting from services performed. *
Required
Please electronically sign below by typing your full, legal name. By signing below, you attest that all information shared in this form is true and accurate to the best of your knowledge. The undersigned acknowledges that he/she has read and understands this agreement. *
Your answer
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