Healing Touch Therapy Spa
Client Information
Email address *
Name: *
Your answer
Birthday: *
MM
/
DD
Street Address(city, state & zip): *
Your answer
Day Phone: *
Your answer
Occupation
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Emergency Contact Name and Phone *
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Referred by/ how did you hear about us?
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Best Way to Contact You? *
Required
Would You Like To Receive Updates and Spa Specials? *
Credit Card Information (number, expiration, CVV, and billing zip code *
Your card will not be charged until the time of your appointment. Note if you do not show up and do not call to reschedule your card will be charged the full amount of your booking.
Your answer
Have you ever received a Professional Massage?
Date of your last massage
MM
/
DD
/
YYYY
Have you ever received a professional Facial?
If so, date of last facial
MM
/
DD
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YYYY
What results are you looking for in your massage or facial session?
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List any exercise activities. including frequency:
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Are you currently under the care of a health care provider or dermatologist? *
If Yes, please explain why:
Your answer
List any current medications and purpose for each:
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