| New Guests |
| Welcome!
In order to make your experience as pleasant and comfortable as possible, we ask for you to fill out our on-line new client form before your visit to Rejuvenation Spa. If you prefer to download a printable version of the form, please click on the following link:
Printable new guest form (PDF)
If, at any time, you have questions regarding your visit, please let us know.
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New Guest form
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* Required field
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| first name:* |
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| last name:* |
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| address:* |
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| city:* |
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| state:* |
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| zip:* |
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| home phone:* |
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| work phone: |
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| email address:* |
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| occupation: |
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| referred by: |
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| date of birth: |
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| sex: |
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| Have you ever received a
massage? |
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| Have you ever received a
facial? |
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| type of massage preferred: |
deep
medium
light pressure |
| Are you taking medication? |
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| If yes, please describe. |
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| What is the primary reason for your
appointment? |
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| Is there a chance you are
pregnant? |
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| If yes, how many months? |
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| Will you consume alcohol within 24
hours of your appointment? |
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| Do you have a history of the
following? |
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| On the day of your visit, it it possible any of
the following symptoms may be present: |
sunburn
inflammation
severe pain
headache
open cuts, bruises,
burns
irritated skin, rash
poison
ivy
cold/flu |
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| Please list any allergies you
have: |
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| Do you have any other medical condition, or are taking any medications I should know about? |
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| Within the last 6 months have you
used, or are you currently using, Accutane or
Retin-A? |
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Please read the following
before sending form:
I understand this spa treatment is not a
replacement for medical care and no diagnosis will be
made.
I am responsible for paying for any
appointment cancellation of less than 24 hours.
Parent and guardian must sign and give consent for guests 17 and under.
All information you submit will be
considered confidential. |
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