Consultation Form - Essential Therapies Spa

Your Name*

First Last

Date*

Your Birthday*

Your Email*

Enter Email Confirm Email

Your Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referred By

Therapist

How often do you receive a massage?*

Regularly
Seldom
Never

Do you have any present concerns or areas to focus on?*

Health Information

Are you currently pregnant?*

No
Yes- 1st trimester
Yes- 2nd trimester
Yes- 3rd trimester

Do you have any allergies?*

Yes
No

Please list all allergies*

Please list any topical medications you're currently taking*

If not taking any medications, write 'none'.

Please list any oral medications you're currently taking*

If not taking any medications, write 'none'.

Do any of the following apply to you?*

Contact lenses
Prothesis
Arm IUD
Metal implants
Hot flashes
None of the above

Are you currently undergoing chemotherapy or radiation?*

Yes
No

If yes, please specify:*

Have you ever been diagnosed with any of the following?*

Cancellation Policy*

I understand pre-payment is included and includes gratuity.
I must give 24-hour notice to receive a refund on my treatment if I need to cancel.
I understand I need to call Essential Therapies Spa at 352-735-0044 and speak with a guest relations associate to cancel; in the event it is after business hours please leave a voice mail and call Riki at 352-267-2006.

By checking this box and providing a digital signature below, you agree to the cancellation policy.

Digital signature*

By typing your name, you agree to the above cancellation policy.

Confidential Consultation

Health Information

Essential Therapies

Hours