Client Intake Form

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Contact (Name & Phone)

Occupation

Height & Weight

Birthday

Referred By

List any medications or supplements you are currently taking (including aspirin):

List any accidents, surgeries or major illnesses, date & description:

List all allergies:

Are you currently pregnant?

If yes, when is your due date?

If Other, please list here:

Please explain any symptoms or conditions you checked:

I affirm the information I have provided on this form is true and accurate, to the best of my knowledge. I agree to inform Ahh Spa of any changes in my health status at successive appointments before receiving any further treatments. I understand that therapists and estheticians do not diagnose illness, disease, or any other physical or mental disorder. I am aware that information exchanged during any session is educational in nature and is not intended as medical advice. I understand that Ahh Spa is not liable for any allergic reactions from products used during my services. All information given on this form is confidential.

I have read and agree to the terms & conditions

I acknowledge I have read over the Cancellation/Spa Policies (listed under the More Tab).