Perfect Harmony Spa / Michelle’s Natural Alternatives, LLC         Intake Form

 

Name - 

 

Address -

 

Phone - 

 

Email - 

 

Past health history summary - 

 

Current health conditions -

 

Do you have a pacemaker or any electrical devices in your body?

 

Do you have deep vein thrombosis, blood clot etc?

 

Are you pregnant?

 

Do you have any health conditions that would contradict getting a massage/ reflexology or other services?

 

Print Name - 

 

Signature - 

 

Date -