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Health Therapy & Beauty Center
Ft Myers Massage and Skincare Center
(239) 900-3005
12791 Kenwood Lane #1001, Fort Myers
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Skin Care Treatments
Full Facial Treatment
Brazilian Wax
Eye Perfection Treatment
Advanced Nácar Treatment
Q-10 Rescue Treatment
Shine Stop Treatment
Infinity Treatment
Ocean Miracle Treatment
Age Defense Treatment
Rgnerin Treatment
Skin Sensations Treatment
Goji Treatment
Purifying Treatment
Massage
About Us
Read Our Reviews
Jenny Fuentes
Spa Rooms for Rent
REQUEST APPOINTMENT
Buy Gift Cards
Skin Care Treatments
Full Facial Treatment
Brazilian Wax
Eye Perfection Treatment
Advanced Nácar Treatment
Q-10 Rescue Treatment
Shine Stop Treatment
Infinity Treatment
Ocean Miracle Treatment
Age Defense Treatment
Rgnerin Treatment
Skin Sensations Treatment
Goji Treatment
Purifying Treatment
Massage
About Us
Read Our Reviews
Jenny Fuentes
Spa Rooms for Rent
Massage Intake Form
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Massage Intake Form
Save time when you arrive to our spa by completing our massage intake form before you arrive. You may also be directed to this form upon arrival if you prefer an electronic version.
Please enable JavaScript in your browser to complete this form.
Name
*
Date of Birth
*
May we contact you about upcoming promotions/discounts?
*
Yes
No
Email Address
Phone
*
How did you hear about us?
*
Do You Prefer Text or Email?
Text
Email
Texting Number
Address
*
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The following information will be used to help plan a safe and effective massage session. Please answer the questions to the best of your knowledge.
Have you ever experienced a professional massage?
*
NO
YES
If YES, how often?
Do you have any allergies to oils, lotions, or ointments
*
NO
YES
If YES, please explain
Do you have sensitive skin?
*
NO
YES
Are you wearing contact lenses, dentures or hearing aids? (Explain)
Do you sit for long hours at a workstation, computer or driving?
*
NO
YES
What pressure do you prefer?
Deep
Medium
Light
Do you have any goals in mind for this massage session? Explain
Please explain any areas of discomfort
In order to plan a massage session that is safe and effective, I need some general information about your medical history.
Are you currently taking any medication?
NO
YES
If YES, please explain
Please check any condition listed below that applies to you:
Contagious Skin Condition
Atherosclerosis
Allergies/Sensitivity
Artificial Joint
Recent Fracture
Fibromyalgia
Swollen Glands
Easy Bruising
Circulatory Disorder
Headaches/Migraine
Back/Neck Problems
Recent Surgery
Epilepsy
Tennis Elbow
Cancer
Heart Condition
Diabetes
Phlebitis
Varicose Veins
Sprains/Strains
Decreased Sensation
Current Fever
Recent Accident or Injury
Joint Disorder / Tendonitis
Osteoporosis
Pregnancy
High/Low Blood Pressure
Carpal Tunnel Syndrome
Explain any conditions you have marked above
I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, its is not a substitute for medical examination, diagnosis, and treatment. Being that massage should not be performed under certain medical conditions, I confirm that I have answered all questions pertaining to medical conditions truthfully. In the event I become injured as a result in whole or part, after the massage, I hereby hold harmless and indemnify the therapist and the company Health Therapy & Beauty Center from all claims and liability. THIS IS A PROFESSIONAL MASSAGE AND ANY SEXUAL REMARKS OR ADVANCES WILL TERMINATE THE SESSION AND WILL BE LIABLE FOR PAYMENT OF THE SCHEDULED MASSAGE.
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Today's Date
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