Client Information Form Please enable JavaScript in your browser to complete this form.Thank you for visiting Serenity Spa & Massage of Naples. Please fill out the following information. Client Information Name *FirstLastEmail *Phone *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth *Gender *FemaleMalePrefer not to sayMassage Therapy Details Have you ever received massage therapy? *YesNoDo you have any of the following today? *SunburnCuts, burns, bruisesInflammationIrritated SkinSevere PainPoison IvyHeadacheFlu or ColdNone of the AboveWhat type of touch do you prefer? *Light/MeditativeHeavy/InvigoratingDeep/Trigger PointWhat are your goals for the massage? *RelaxationInjury RehabilitationHigh Activity Level / MaintenanceOther (please let us know)Areas of body to focus onAreas of body to avoidEmergency Contact Name *Emergency Contact Phone *Consent and Authorization Checkboxes *I confirm that the above information is accurate. I also understand that this massage service is not a substitute for medical care and that no diagnosis will be made.Signature * Clear Signature Submit For any questions or to learn more about our services, feel free to reach out: Phone (239) 403-1000 Hours 9 AM - 9 PM Monday through Sunday Address 1404 Goodlette-Frank Road, Naples, FL 34102
