• Home
  • Available Services
  • Energy & Wellness
  • Massage and Bodywork Services
    • Signature Services
    • Facials
    • Massage
    • Energy & Intuitive Services
  • About
    • Our Team
    • FAQ
    • Contact
    • Intake form
    • Appointment Policies
    • COVID-19 Screening

    Lifespa Wellness Center Therapeutic Massage Intake Form

    Middle Name
    Including area code 123-456-7890
    Including area code 123-456-7890
    Including area code 123-456-7890

    Covid 19 Symptoms:

    Covid 19 Information:
    During a massage session, it is not possible to maintain social distancing. You and your therapist will be sharing a treatment room in close contact with one another for an extended period of time. In an attempt to reduce the risk of spreading the Corona Virus, we ask that all visitors to Lifespa Wellness Center and their massage therapists wear a mask throughout their entire session and visit. Forehead temperatures will be taken upon entry. We ask that all visitors wash their hands or use our hand sanitizer stations upon arrival.​

    How are you feeling today?

    In the last 5 years have you had any of the following health conditions?


    Additional Information:

    ​I consent to receiving massage. I understand that massage therapy is not a substitute for medical treatment and that no medical diagnosis will be made. I understand that any information I receive from individuals at Lifespa Wellness Center is educational in nature and is to be used at my own discretion. I understand that payment is due upon completion of each visit. I understand that cancellations or reschedules must be made 24 hours in advance, and failure to do so may result in a missed-appointment fee totaling 50% of the normal cost of the session(s).

    Signature

    Entering your full name will act as your signature
    If you are under the age of 18, a legal guardian's signature is required.
    Guardian, entering your full name will act as your signature.
    i.e. Parent, Grandparent
    By submitting this form you are agreeing that the information disclosed is true and correct. 

    If you click submit and the page does not redirect you and confirm your information has been submitted, you may have missed a required field.  Not all fields are able to be highlighted if missed, such as missed check boxes.
Submit
Picture
Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon
Join our Email List
For Email Newsletters you can trust
About Us
Schedule Today!
FAQs

LWC Policies
Career Opportunities
Contact Us

The Spa Life Blog

Spa
Facials
Massagel
Signature Services


Wellness
LIFEWORK™ Therapy
Acupressure
Intuitive Readings
Energy work
Reiki


Products
Jane Iredale
Éminence
ODE
Comphy Sheets & Linens

Red Flower Body Products
Clear My Head


Accessories
Exclusive Inspirations Jewelry


LOCATION
345 Cardinal Lane Suite 6, Green Bay, WI  54313
920-434-2204

Copyright© 2013 Lifespa Wellness Center
HOURS UNTIL FURTHER NOTICE ARE BY APPOINTMENT ONLY
Monday 8 AM - 5 PM | Tuesday - Thursday 9 AM - 6 PM

Friday 8AM - 5 PM | Saturday 8 AM - 2PM
Extended service hours are available Tuesday through Thursday by appointment
  • Home
  • Available Services
  • Energy & Wellness
  • Massage and Bodywork Services
    • Signature Services
    • Facials
    • Massage
    • Energy & Intuitive Services
  • About
    • Our Team
    • FAQ
    • Contact
    • Intake form
    • Appointment Policies
    • COVID-19 Screening