Client Intake Form

Please fill out the information below accurately to ensure we can provide the best care tailored to your needs.

Click here to download and print the  form.

    Name:
    Date of Birth:
    Address:
    Phone Number:
    Email:

    Sculptural Facelifting Massage Information

    Please provide information on any recent treatments you’ve received.

    Botox (How recent?):
    Threads (How recent?):
    Fillers (How recent?):
    Facelift (How recent?):

    Have you had any of the following treatments in the last month?

    List any prescription creams or oral medications provided by a dermatologist:

    Health Information

    Check all that apply:

    Waiver & Release Policy

    I understand that the services provided by Total Wellness with Erica are non-medical wellness services and are not a substitute for medical care, diagnosis, or treatment. I affirm that I have disclosed all relevant health information accurately and will notify the practitioner of any changes to my health status. I voluntarily consent to receive these services and release Total Wellness with Erica and its practitioner from liability for any adverse reactions resulting from undisclosed or inaccurate information.

    I AGREE TO THE ABOVE WRITTEN POLICIES AND UNDERSTAND THIS AGREEMENT AS MY LIABILITY WAIVER AND RELEASE WAIVER FROM ALL TREATMENTS/FUTURE TREATMENTS WITH Erica Coughlin/Total Wellness With Erica.

    Your Name:
    Today's Date: