Massage/Salt Cave/Energy Work Intake Form Client intake form that needs to be filled in prior to their session starting Today's Date Date Format: MM slash DD slash YYYY Reason For Visit:* Massage Therapy Salt Cave (Halo Therapy) Energy Work Skin Care Date of Birth:* Date Format: MM slash DD slash YYYY Name* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Salt lnhalation Therapy has been known to assist in alleviating the symptoms of many respiratory issues. Please Indicate If you have any of lhe following conditions:* Allergies, Eczema, Psoriasis Open Sores and Wounds Easy Bruising Recent Accident or Injury Recent Fracture Artificial Joints Sprains/Strains Current Fever Swollen Glands Allergies/Sensitivity Heart Condition High or Low Blood Pressure Circulatory Disorder Varicose Veins Atherosclerosis Phlebitis Deep Vein Thrombosis/Blood Clots Joint Disorder/Osteoarthritis Epilepsy Cancer Diabetes Decreased Sensation Back/Neck Problems Fibromyalgia TMJ Carpal Tunnel Syndrome Tennis Elbow Pregnant None Of These Disclaimer:Bethesda Salt Cave and its employees accept no responsibility for your valuables. We at no timee, make any claims that our salt cave will cure any illnesses. By clicking submit below, you acknowledge that you have advised us of any conditions which you may be sensitive to or are suffering from. Bethesda Salt Cave and its personnel wiII not be held accountable for any injuries and/or conditions arising from salt Inhalation or massage therapy.