Intake - Columbia SC | Serenity Therapeutic Spa

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Any health conditions under current treatment? *

How stressed are you?

Selected Value: 1

1-10 were 10 is the worst

Any health conditions that affect your liver? *

If yes, please explain

Have you ever had cancer?

If yes, please explain

Do you exercise? *

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How much weight do you want to lose? *

Are you embarrassed about your weight/appearance?

Yes
No

How long have your had issues with your weight?

How important is weight or size reduction to you?

Selected Value: 1

1-10 were 10 is the most important

Are other members of your family overweight?

Yes
No

Do you feel tired, run down, or out of energy?

Yes
No

Agreement:

I clearly understand and agree that all services rendered are charged directly to me, and that I am personally responsible for payment.

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Melt That Fat Away Intake

Cranial Sacral Therapy

Red Light Therapy

Lymphatic Drainage

Agreement:

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