Cerenity Medspa Intake Form
Buyer First and Last Name*
Mobile phone*
Email*
Address Street*
Address Apt #, Unit #
City*
State*
Zipcode*
Employer
Age*
Birthday*
Gender*
How did you hear about us? (i.e. Facebook, Google, Drive-By, Mail, Friend?) If Friend First And Last Name So We Can Thank Them!*
Emergency Contact First and Last Name*
Emergency Contact Phone*
Emergency Contact Relationship to you*
What membership are you interested in? Please check all that apply:*
Detox Membership: Regain Membership Includes 1 Herbal Detox Body Wrap
Detox Membership: Reset Membership Includes 2 Herbal Detox Body Wrap
Detox Membership: Restore Membership Includes 4 Herbal Detox Body Wrap
Aesthetic & Massage IV Membership: Relax Membership Includes 1 Service Choose From 3
Aesthetic & Massage IV Membership: Refresh Membership Includes 2 Service Choose From 3
Aesthetic & Massage IV Membership: Rejuvenate Membership Includes 3 Services
Mind Body Spirit Membership: 4-Pack Choose From Yoga - Barre - Pilate Reformer
Mind Body Spirit Membership: 8-Pack Choose From Yoga - Barre - Pilate Reformer
Mind Body Spirit Membership: 12-Pack Choose From Yoga - Barre - Pilate Reformer
None of the above
Preferred Communication For Appointment Reminders, Promo's, News and Special Offers By:*
Phone Call
Email
Text
Weight
Height
What is your specific concern about your skin? Please respond with NA if non applicable.*
Any specific questions for us?
Reason for visiting Cerenity Integrative Medspa?*
Pleasure & Relaxation
Health Related
Pain Relief
Detox & Rejuvenation
Special Ocassion
Other
May we add you to our emailing list?*
Yes
No
Food allergies?*
Allergies to Medication ?
Allergies to Sulfur?*
Yes
No
List all medications you are currently taking and dosages
What are the end results you are wishing to accomplish?*
Have you ever had an allergic reaction to cosmetic products? If yes, pleae explain
Are you under the care of a dermatologist ?
Are you taking Accutane?
Yes
No
Are you using Retin-A or any Rentinal, Salicylic, or Glycolic products?
Yes
No
Do you currently use Cerenity Products? If yes, which ones?
What is your skin type?
Dry
Oily
Combination
Mature
Acne
What skin care line do you use?
Areas of the body to be avoided?*
What is the reason?
Please give an explanation of pain, tingling, numbness or spasms.
Have you been in an accident or suffered an injury? If yes, please explain.
What type of massage or bodywork pressure do you prefer?
Light Pressure
Moderate Pressure
Deep Pressure
What did you like or not like about your session?
If yes, how recently?
Are you on blood thinner?
Yes
No
Have you ever experienced a professional massage or bodywork session?
Yes
No
Are you currently receiving chemotherapy?
Yes
No
Have you stopped chemotherapy? If yes, how long ago?
Do you have other medical conditions?
List all vitamins and supplements you are currently taking below.
Medical history: If you have a specific medical condition or specific symptons, massage/bodywork/wraps may be contraindicated. A referal from your primary care provider may be required.*
Heart problems
Cancer/cancer therapy
Skin Condition
Thyroid
Headache
Epilepsy
HIV/Aids
Diabetes
Pregnant or Lactating
Hepatitis
High/Low Blood Pressure
Back/Neck Pain
Stroke
Fibromyalgia
Lupus
Arthritis
None
Other
Fill in the blank: I agree that my face _______ be shown in any public photos.*
Yes
No
Client Testimonial