Con dential Client Intake Form
Welcome to Allyu Spa! Please take a moment to answer the following questions. This information is con dential and we
comply with HIPAA regulations. Each service provider will ask a few individual questions to customize your service and best
meet your needs. Please consider taking this time to relax and be aware of your body in its present state. We hope you enjoy
your experience with us.
Name ____________________________________________ Birthdate and Year _____________________________________
Street Address _____________________________________ City ____________________ State ______ Zip _____________
Telephone (Home) __________________________________ Phone (cell/wk) ________________________________________
Email _____________________________________________ Shoe Size (for spa sandals) _______________________________
Referred by ________________________________________
Do you have a gender preference for your bodywork practitioner? No Preference Male Female
Please circle any of the following that pertain to you:
anxiety arthritis cancer depression headaches hepatitis
high blood pressure low blood pressure pregnant surgeries ___________________________________________
Do you have any other medical concerns or conditions? _________________________________________________________
Please list any allergies or sensitivites: ________________________________________________________________________
Medications - topically or orally: _____________________________________________________________________________
Your appointment is reserved speci cally for you. If you are unable to arrive at the agreed time, we will need to complete the
appointment as scheduled. If you are unable to provide 6 hours notice for changes or cancellation, a 50% fee will be charged.
If you miss your appointment with no noti cation, full cost of the service will be charged. Thank you for your cooperation.
I con rm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information
that may be relevant to my treatment.
Signature _________________________________________________________ Date _________________________________
If under 16 years of age, parent/guardian signature _____________________________________________________________
The art of healing comes from nature, not from We must be the change we
the physician. Therefore, the physician must wish to see in the world.
start from nature, with an open mind. - Mahatma Gandhi
- Philip Aureoulus Paracelsus