SpaClients

Your Name (required)

Bus Phone (required)

Res Phone (required)

Address

City

State

Zip

Who referred you?

Are you under a doctors care?
 yes no

Health Problems
 Cancer Epilepsy Heart Allergies Arthritis Varicose Veins Headaches High/Low Blood Pressure Cardiac or Circulatory problems Contagious Diseases Joint Swelling

Do you?
 Bruise easily Wear Contact Lenses Suffer from Stress Have Back Pain Pregnant Skin Disorders Any Tension or Soreness Any surgery or injuries in the last 2 years Have Numbness/Stabbing pain Sensitive to touch or pressure Have any medical conditions I should be aware of

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