Genesis Wellness Lounge

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Hello there!

Please fill out the form below. Once you submit it, you will be taken to the booking link to schedule your sessions.

CLIENT INFO:

First Name *

Last Name *

Email *

Phone *

Groupon Redemption Code *

MEDICAL HISTORY:

Any Known Medical Conditions *

Current Medications *

Any Allergies? *

Did you have a recent surgery? If so What type?

Do you have any history or are you experiencing the following:

Epilepsy (Seizures)

Liver condition

Heart condition

Kidney/Urinary Tract infection

High Blood Pressure

Diabetes

Cancer

HIV

Skin Issues (Rash/Sensitivity)

Metal Pins/Plates/Rods

Cardiac Pacemeker

Hearing Aid

Currently Pregnant, trying to get pregnant or breastfeeding

None

What areas will we focus on based on your package?

Stomach

Waist

Back

Thighs

Arms

Chin/Neck

Face

Flank

ADDITIONAL INFO:

Any Additional Comments, Questions Or Special Requests?

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