The Lilypad Massage Spa
Client Intake Sheet
Complete by hand and bring to your appointment. Your first appointment begins with a free 15-minute consultation.
Your Details
Full name
Date of birth
Phone
Appointment date
Emergency contact name
Emergency contact phone
Your Care Goals
What brings you in, and what would you like help with?
Areas of discomfort, swelling, or sensitivity, and when they began
Health History to Discuss
Please include relevant details and dates. If you prefer, discuss these privately during your consultation.
Medical conditions, recent surgery or injury, and any care restrictions from your healthcare provider
Lymphedema or related concerns: diagnosis (if any), affected areas, previous care, and compression garments
Current medications, allergies, skin sensitivities, or pregnancy
Comfort & Questions
Areas to avoid, positioning needs, or other preferences
Questions for your therapist
For discussion with your therapist at your appointment. No information is submitted through this page.