Exhale Spa East – New Client Intake Form

First name

Last name

Address

Postcode

Phone


Your primary contact number

Your email

Intake date

Date of Birth

Health History

If you are pregnant, how many weeks?

Other (please explain)

Skin Care

Are you under the care of a Dermatologist?

Do you use any prescription skin products?

Have you had a:

Do you have any skin sensitivities or irritants?

Notes

Disclaimer

SIGNATURE

Date

Therapist

*PLEASE CLICK SUBMIT A SECOND TIME - AFTER DOUBLE-CHECKING ALL INFO IS CORRECT*