Client Intake Form

If this is your first day spa visit, you will be asked to complete a new client intake form to provide us with medical and contact information.

This is another reason to arrive early. To save time, you may print the form here and complete or enter your information securely on-line prior to your visit.

All clients should complete page one. In addition, clients receiving Skin Care should complete page two and clients receiving Massage Therapy should complete page three.

Privacy Policy
Tranquility Day Spa does not collect information from visitors to this site, nor are these site statistics made publicly available. We do not sell or in any manner reveal client or user information to any services, third party or otherwise, collecting statistics or gathering information. We do not solicit information from visitors to this site or clients for any purpose but normal business transactions. Information supplied by users and clients is privileged, private and protected, only and expressly for business use by the owners and proprietors of Tranquility Day Spa. Your privacy is important to us, we value your business and respect your right to privacy.

About You

First Name (required)

Last Name (required)

Street Address (required)

City/Town(required)

State(required)

Zip(required)

Mailing Address the same?(required)
 Yes No

Home Phone

Mobile Phone

Email

Birthdate

Profession

How did you hear about us?
If client referral please provide first/last name of referral so that person may receive recognitition.
 Client Referral Email Postcard Website SPA Finder Review Site Walked by Advertisement Other

General Health

Rate your general health
 Excellent Good Fair

Do you eat a balanced diet?
 Usually Always Not usually

Are you pregnant?
 Yes No

Do you have any special skin problems to your face or body?
 Yes No

Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products?
 Yes No

Do you suffer from sinus problems?
 Yes No

Have you ever seen a specialist for nail infection or fungus?
 Yes No

List any allergies.

Rate your general consumption of the following:

Caffieine
 Light to none Moderate Heavy

Alcohol
 Light to none Moderate Heavy

Tobacco
 Light to none Moderate Heavy

Sugar
 Light to none Moderate Heavy

How much plain water do you consume daily?

Do you wear
 Contacts Dentures Prosthesis

Check any conditions you may have
 Allergies Arthritis Blood Clots Carpal Tunnel Circulatory Contagious Disease Diabetes Heart Disease High Blood Pressure Low Blood Pressure Muscular Injury Respiratory Spinal Injury Other

Check any chronic symptoms you may have
 Abdominal Pain Chest Pain Constipation Digestive Problems Dizziness Depression Fatigue Insomnia Migraine Headache Sinusitis Other

Have you been hospitalized in the last year?
 Yes No

Check services for this visit
 Hands and/or Feet Skin Care Massage Waxing

Skin Care

What skin care products do you use?

On Face
 Soap Cleanser Toner Moisturizer Exfoliator (scrub)

On Body
 Soap Shower Gel Exfoliator (Scrub) Moisturizer

Have you ever had chemical peels, microdermabrasion or any resurfacing treatments?
 Yes No

Check products that you are currently using containing the following ingrediants
 Glycolic Acid Lactic Acid Hydroxy Acid Vitamin A Derivatives

Check areas of skin breakouts, if any
 Hairline Forehead Chin Cheeks Jawline

Check all that apply
 Experience oily shine during the day Blush easily when nervous Tendency to redness Burning, itching sensation on skin

Check if you have had a reaction to any of these items
 Cosmetics Medicine Iodine Pollen Food Hydoxy Acids Animals Sunscreen Other

Check if you experience these conditions on your skin
 Flakiness Tightness Obvious dryness

Verification

Please enter any two digits (required)

Example: 12

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15 Spring Street, Watertown, MA
(617) 955-9881 | sstout@watertownspa.com

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