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Guest Information Form

This document contains a client information form for Spa Phoenix Day Spa and Salon. It requests basic contact information such as name, address, phone numbers and email. It also asks how the client learned about the spa and includes health history questions to ensure treatments can be provided safely, asking about medical conditions, medications, allergies and prior reactions.

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maria maria
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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53 views2 pages

Guest Information Form

This document contains a client information form for Spa Phoenix Day Spa and Salon. It requests basic contact information such as name, address, phone numbers and email. It also asks how the client learned about the spa and includes health history questions to ensure treatments can be provided safely, asking about medical conditions, medications, allergies and prior reactions.

Uploaded by

maria maria
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Welcome to Spa Phoenix Day Spa and Salon.

Please help us to serve you by completing the client information form.


Date________/________/________
mo

day

yr

First name______________________________________________________________
Last name_______________________________________________________________
Salutation (please indicate one) Mr. / Mrs. / Ms. / Miss / Dr.
Address Line 1___________________________________________________________
Address Line 2__________________________________________________________
City_____________________________________State__________Zip_____________
home phone (_____) _____-________
work phone (_____) _____-________
other phone (_____) _____-________
email address:___________________________________________________________
I wish to receive Spa Phoenix newsletter/internet special notices. Yes / No
Gender_____________
Date of Birth ________/________/________
Occupation________________________________________
How did you learn of our spa and salon? (please indicate all that apply)
Dr. Galumbeck
TV
Radio
Yellow pages
Newspaper
Drove by
A Web link
Gift Certificate
Search engine
Referred by____________________
[Link]
Other__________________________
for your comfort and safety, please complete the health history information
on the reverse of this page.

Health History
Have you ever had a reaction to personal care products?
Yes No
If yes, please list________________________________________________________
Are you allergic to any medications?
If yes, please list________________________________________________________
Are you taking any medications at present?
If yes, please list________________________________________________________
Do you smoke?

Yes

No

Are you pregnant?

Yes

No

If yes, packs per day?___________

Do you have a history of any of these health conditions?


High Blood Pressure
Bleeding Problems
Heart Problems
Claustrophobia
Skin Condition
Nail Fungus
Spinal Problems
Blood Clots
Acute Injury

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No

Diabetes
Seizure
Cancer
Thyroid Problems
Radiating Pain
Systemic Disease
Varicose Veins
Arthritis

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

If yes, please elaborate___________________________________________________


________________________________________________________________________
Have you ever had surgery?
Yes No
If yes, please explain_____________________________________________________
Do you wear contact lenses?

Yes

No

Do you have any other medical conditions of which we should be aware? Yes No
If yes, please list________________________________________________________

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