Melt Spa + MassageClient Intake Form Call Now Book NowPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 6NamePhoneDate of BirthAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Occupation Employer Emergency Contact Relationship PhoneHow did you hear about us? NextMassage Information Have you had a professional massage before?YesNoWhat type of massage are you seeking?RelaxationTherapeutic/Deep TissueWhat pressure do you prefer?LightMediumDeepDo you have any allergies or sensitivities?YesNoPlease Explain Are there any areas (abdomen, feet, face, etc.) you do not want massaged?YesNoPlease explain What are your goals for this treatment session?Please choose any areas of discomfort:ABCDPlease specify which partBy signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.Signature Clear SignatureDate you on high-risk PreviousNextFacial InformationHave you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?YesNoIf yes, was it within the last month?YesNoYour Skin Type:Normal/ComboOilySensitiveDryMild AcneModerate AcneMature & AgingSkin goals and concerns: What skin products are you currently using? What makeup products are you currently using? Do you wax your face on a regular basis?YesNoIf yes, when was the last time? Are you using Retin-A?YesNoAre you using Benzoyl Peroxide?YesNoAre you using Accutane?YesNoAre you on antibiotics?YesNoHave you ever experienced a reaction to any of the following?CosmeticsMedicineIodine (Shellfish)LatexFood/FruitPollenFragranceSunscreensAlpha hydroxy acidsI have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.Signature Clear SignatureDate PreviousNextPlease indicate any of the following that apply to you:First ChoiceBlood ClotsCancerChemotherapyCirculatory IssuesCold SoresDiabetesEczemaFibromyalgiaHeadaches/MigrainesHeart AttackHigh Blood PressureHormonal imbalancesLow Blood PressureHysterectomyJoint replacement(s)Kidney DysfunctionLactatingNeuropathyNumbnessPregnantPsoriasisRecent surgeriesSprains or StrainsStrokeThyroidOther:OtherPreviousNextAre you taking any medications?YesNoIf yes, please list name and use: Are you currently pregnant?YesNoIf yes, how far along? Any high-risk factors? Do you suffer from chronic pain?YesNoIf yes, please explain What makes it better? What makes it worse? Have you had any orthopedic injuries?YesNoIf yes, please list: Any other concerns or issues you would like to inform us of? PreviousNextI agree to the following:I understand that my Massage Therapist/Esthetician may end the service at any time if they are uncomfortable.I understand that my session must promptly end if client initiates any verbal or physical contact that is sexual in nature.Female breasts must be draped and not engaged in massage without written consent.Draping of the genital area and gluteal cleavage will always be used during the session(s) of ALL clientsI have completed this form to the best of my ability and knowledge and agree to inform my therapist and/or technician if any of the above information changes at any time. I will inform the therapist and/or technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. The treatments I receive are voluntary and I agree to waive all liabilities toward my therapist, my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.Client Name (Printed)Client Signature Clear SignatureDate Therapist Signature Clear SignatureDate Esthetician Signature Clear SignatureDateSubmit
