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Pure Spa Wellness

Natural Nutmeg 2023 Winner

Home of SKINtuitive™ Esthetics

Nervous System-Supportive Skincare

Manual Lymphatic Drainage
Intake Form

Please fill out the following form before your treatment.

First Name

Last Name

Email

Date of Birth

Phone

Address

Emergency Phone Number

Referred by

What do you do for work?

Stand

Walk

Lift

Computer

School

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Check all that apply:

Headaches/Migrains

Neck Pain

Shoulder Pain

Numbness/Tingling

Sprains/Strains

Check all that apply:

Carpal Tunnel

Thoracic outlet syndrome

Tennis Elbow

Vertigo

Plantar Fasciititis

Back Pain/Discomfort:

Upper

Middle

Lower

Sciatica

Check all that apply:

Piercings

Depression

Anxiety

Abuse- sexual-physical-verbal-emotional-financial

Check all that apply:

Broken Bones

Car Accidents

Surgries

Check all that apply:

Brest Surgery/ Reduction/enhancement

Pregnant

C-Section

Hysterectomy

If you check anything in the bottom two sections please explain in detail.

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Hours:

Monday - Wednesday - Friday: 10-6

Saturday: 9-1

By Appointment only

Location:

Riverdale Farms Shopping

152 Simsbury Road

Building 9 Second Floor

Avon, CT 06001

Black Owned

Woman Owned

203-910-3970

PureSpaWellnessCT@yahoo.com

© Copyright 2019 Pure Spa LLC

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