SPA/SALON CLIENT INTAKE FORM TEMPLATE

DATE	TENDING HOST/HOSTESS
CUSTOMER INFORMATION
NAME
GENDER	HOME ADDRESS
DATE OF BIRTH
HOME PHONE
ALT. PHONE
EMAIL
Specify areas you would like us to target.
Please circle any of the following conditions you've had a health issue with.
arthritis anemia cancer convulsions seizures migraines osteoporosis	bladder trouble chest pain high blood pressure kidney trouble heart trouble	poor circulation sinus trouble asthma indigestion dermatitis epilepsy	broken bone measles hepatitis tuberculosis neck pain diabetes artificial joints	_______________ _______________ _______________ _______________ _______________	_______________ _______________ _______________ _______________ _______________
Please elaborate on any conditions circled above.
PAYMENT INFORMATION
PAYMENT TO	PAYMENT DATE
RECEIPT NUMBER	AMOUNT PAID
PAYMENT METHOD
RECEIVED FROM	RECEIVED BY
ACCOUNT INFO	PAYMENT PERIOD
ACCT BALANCE	THIS PAYMENT	BALANCE DUE	FROM
THROUGH
PAYMENT FOR	ADDITIONAL INFO
INSURANCE INFORMATION
NAME OF CARRIER	INSURED’S DATE OF BIRTH
NAME OF INSURED	GROUP NUMBER
SUBSCRIBER ID	SIGNATURE

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