Elite Health & Beauty Client Intake Form
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Email *
Last Name, First Name: *
Sick Policy – Elite Health & Beauty recognizes that both massage therapists and clients are vulnerable to infections and therefore ask clients to cancel appointments when they are feeling unwell. If you have any of the following contagious illnesses the massage session will be rescheduled: Diarrhea, Vomiting, Fever, Chicken Pox, Measles, Mumps, Meningitis, Hepatitis A, Conjunctivitis, Rubella, Head Lice, Impetigo, Influenza, Pneumococcal Disease, Polio, Ringworm of the body, feet or scalp, Scabies, Thrush, Whooping Cough, Dry Cough, and the Common Cold. Have you experienced any of the above symptoms within the past 12-24 hours? *
In the midst of Covid-19, we will continue our cleaning and sanitation procedures and have added additional steps to social distance: Spacing appointments to have extra time to disinfect all areas and lessen client to client interaction. Require all clients to wear a face mask or cover while in our facility. Have clients complete an online intake form to limit waiting room time. Ask that clients remain in their vehicles, clients will receive a text or call with instructions to enter the facility. Florida Department of Health is requesting proper PPE be utilized, please stop at the hand sanitizer station once you enter and remember to wear your mask. If you do not have a mask, we have disposable ones available for a purchase price of $3. If you have or have had any symptoms related to Covid-19 within the past 14 days or have been in contact with someone who has had included but not limited to fever, cough, sore throat, runny nose, or difficulty breathing, please notify our staff. If you are currently experiencing any of the listed symptoms, please do not enter our facility. *
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COVID-19 affects different people in different ways. Infected people have had a wide range of symptoms reported – from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms may have COVID-19: Fever or chills, Cough, Shortness of breath or, difficulty breathing, Fatigue, Muscle or body, aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, DiarrheaLook for emergency warning signs for COVID-19. If someone is showing any of these signs, seek emergency medical care immediately: Trouble breathing, Persistent pain or pressure in the chest, New confusion, Inability to wake or stay awake, Bluish lips or faceCall your medical provider for any other symptoms that are severe or concerning to you. *
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Date of Birth: *
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Address: *
Occupation: *
Phone Number: (no dashes) *
Emergency Contact: (Name) *
Contact Number: *
Have you had a professional massage before? *
If yes, How often and when was your last massage? *
Do you have difficulty lying on your chest, back, or side? *
If “Yes” explain:
Do you have any allergies to oils, lotions, or ointments? *
Please Explain:
Do you have sensitive skin? *
Are you currently under medical supervision? *
Please Explain:
Do you see a chiropractor? If so how often? *
Are you pregnant? If "Yes" how many weeks? *
Are you uncomfortable with any of the following areas being massaged? *
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Are you currently taking any medications? If so please list: *
Please check any condition(s) listed below that applies to you: *
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Please check any condition(s) listed below that applies to you: *
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Please check any condition(s) listed below that applies to you: *
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Please check any condition(s) listed below that applies to you: *
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Wavier & Signature:
(Check all that apply)
Please read in its entirety *
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Client Electronic Signature: *
Please list all areas that apply: Example ( tight shoulders, pain in left hip, mid to low back pain and right calf spasms. For more direct areas please list number(s) *
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Please arrive 5-10 minutes early for your appointment. Please consider travel time. Once you have arrived, PLEASE remain in your vehicle and call or text “Here” (863) 999-4047 so I know that you have arrived. The doors will be locked. No Call/No Shows or last minute cancellations will required a $15 reschedule fee. Late arrivals may result in shorter session time due to following appointments. *
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Elite Health & Beauty
Phone: (863) 999-4047
Web: elitehealthandbeauty.me/book
Email: elitehealthnbeauty@yahoo.com
Serving Winter Haven & Lakeland
MM39659 MM36008
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