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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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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
Wood Therapy Intake Form
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Wood Therapy 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
*
First
Last
Phone
*
Date of Birth
*
Address
*
Address Line 1
City
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Maine
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South Carolina
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Tennessee
Texas
Utah
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West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation
How did you hear about us?
any all yes,
May we contact you about upcoming promotions/discounts?
*
Yes
No
Preferred contact method
*
Text
Email
Email Address
Texting Number
Are you currently taking any medications?
*
Yes
No
If yes, please explain
Please check any condition listed below that applies to you
Contagious Skin Condition
Easy Bruising
Cancer
Current Fever
Atherosclerosis
Circulatory Disorder
Heart Condition
Recent Accident or Injury
Allergies/Sensitivity
Headaches/Migraine
Diabetes
Joint Disorder
Tendonitis
Artificial Joint
Back/Neck Problems
Phlebitis
Osteoporosis
Recent Fracture
Recent Surgery
Varicose Veins
Pregnancy
Fibromyalgia
Epilepsy
Sprains/Strains
High/Low Blood Pressure
Swollen Glands
Tennis Elbow
Decreased Sensation
Carpal Tunnel Syndrome
Explain any conditions you have marked above
What is your main areas of focus/problem? (check all that apply)
Abdomen
Arms
Upper Back
Calves
Neck
Waist
Inner/Outer Thighs
Hips
Buttocks
Lower Back
Other
Consent - Please initial each statement to acknowledge
*
I understand that Wood Therapy Body Sculpting treatments are not recommended if I am pregnant, breastfeeding, have a lymphatic disorder, acute illness or contagious disease, fever, skin disease, Bell's Palsy, or active cancer.
I understand that neither Health Therapy & Beauty Center nor this agreement provides a guarantee of results.
I understand wooden tools will be used during this service. If I feel uncomfortable, I will immediately inform the practitioner so adjustments can be made.
I understand there are no guarantees to results.
I understand and acknowledge that payments for services are non-refundable.
I understand I may experience mild discomfort or bruising from the pressure and technique, which should subside within a week.
I agree to inform Health Therapy & Beauty Center immediately if my health history changes.
I agree that I have answered all health questions truthfully and to the best of my abilities.
I certify that the information on this intake form is true and acknowledge that misrepresentation of my health history may result in injury.
By my signature below, I certify that I have read and understood the contents of this consent form.
Please initial each statement below to indicate your understanding and agreement.
Photo Consent
*
I give permission for Health Therapy & Beauty Center to take my photo for internal documentation only.
I give permission for Health Therapy & Beauty Center to take and use my photos on their website, social media, and other promotional materials.
I do not give permission for any photos to be taken.
Please indicate your preference for photo documentation and usage.
Signature
*
Clear Signature
Date
*
Submit Intake Form
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