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Health Therapy & Beauty Center

Ft Myers Massage and Skincare Center

(239) 900-300512791 Kenwood Lane #1001, Fort Myers

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Facials
Waxing
- Brazilian Wax
- Hair Removal – Waxing
Massages
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Buy Gift Cards
Facials
Waxing
- Brazilian Wax
- Hair Removal – Waxing
Massages
Read Our Reviews

Salmon DNA and Exosome Facials

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Salmon DNA and Exosome Facials

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 select the treatment you are receiving today *

Salmon DNA Facial
Exosome Facial
Combination Salmon DNA + Exosomes

Full Name *

First

Last

Date of Birth *

Phone Number *

Email Address *

Do Client conditions

Address *

Address Line 1

City

State

Zip Code

Are you currently pregnant or breastfeeding? *

Yes
No

Do you have any of the following: Skin conditions or diseases? *

Yes
No

Recent facial or dermatological treatments? *

Yes
No

Known allergies? *

Yes
No

Chronic illnesses (please list)

List all medications or supplements you are currently taking

List any allergies (including skincare products, anesthetics, latex)

Photographic Consent *

I consent to photos being used for internal documentation only.
I consent to photos being used for marketing/advertising/website/social media etc.
I do not consent to any photos.

Client Signature *

Clear Signature

Date (Client) *

Additional comments

Contact Info

Location:
12791 Kenwood Lane #1001
Ft Myers, FL 33907
Phone:
(239) 900-3005
Business Hours:
BY APPOINTMENT ONLY
Mon - Friday: 8 AM - 6 PM
Sat: 8 AM - 12 PM
Sun: Closed

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Intake Forms

FB 9764846 / MA 94290 / MM 43440

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