Intake Form for Self Care Spa

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Welcome! Please fill out this form to get started with some self care 🌴

Email *

First Name *

Last Name *

Phone Number *

Address *

Your Birthday *

YYYY

How did you hear about us? *

If you were referred*, please list the name of who referred you.

Have you experienced any of these symptoms in the past week? *

Fever

Shortness of Breath

Loss of smell

Dry Cough

Fatigue

None of the Above

Other:

Required

Your Service *

Lash Extensions

Skincare Facials

Therapeutic Massage

Waxing

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