Healing Oasis Massage and Wellness
Esthetician Intake Form
Patient Demographic Information
Please provide below
Today's Date:
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-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth (DD-MM-YYYY)
*
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Email Address
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Would you like to receive text message reminders for your appointments?
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Yes
No
Occupation
*
Emergency Contact Information
Name
*
First Name
Last Name
Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
How did you hear about our services? (Check all that apply)
*
Website
Friend/Family
Google Ads
Location
Large Truck Sign
Google Search
Questionnaire
1) What is your main goal for today's treatment?
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2) Have you had a facial before? When?
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3) Do have you have any special skin problems or concerns pertaining to your face or body?
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Yes
No
If yes, please specify:
4) Do you use Retin-A, Renova, AHA, or Retinol Derivative products?
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Yes
No
If yes, please specify:
Has this product been used in the last 3 months? If so, when:
5) Have you ever had chemical peels, laser or microdermabrasion?
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Yes
No
If yes, please specify when:
6) What areas of concern do you have regarding your skin?
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Breakouts/Acne
Blackheads/Whiteheads
Excessive oil/Shine
Dryness/Dehydrated
Wrinkles
Dull Skin
Pigmentation
Other
Do you have allergies/Skin sensitivities? Please specify:
7) What skin care products are you currently using?
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Face Soap/Cleanser
Toner
Day/Night Moisturizer
SPF
Exfoliator/Scrubs
Masks
Eye Products
Other
Informed Consent for treatment, Therapy and Care
I understand that Massage Therapists cannot diagnose medical conditions, legally and ethically cannot provide any medical advice outside of their specific scope of practice as a Registered Massage Therapist and cannot provide prescription and or advice on medications or dietary supplements. I hereby acknowledge that I am aware of the above noted restrictions and will direct any questions I may have regarding the above noted to a registered physician. I have informed and disclosed all applicable and relevant health information to Healing Oasis. I acknowledge and hereby provide permission to Healing Oasis Massage and Wellness to proceed with treatment.
Signature
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Cancellation / No Show Policy
I hereby acknowledge that I will provide a notice for any cancellation of appointments at least 24 hours inadvance. If I fail to provide notice, I will comply and pay the full cost of the scheduled treatment. Failure to provide notice is accompanied with failure to attend, or late cancellation of appointments.
Signature
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COVID Questionnaire
In the past 14 days, have you experienced any of the following symptoms?
Severe difficulty breathing, shortness of breath at rest and/or severe chest pain?
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Yes
No
Sore throat, runny or stuffy nose, chills?
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Yes
No
Fever, new onset of a cough or worsening of chronic cough?
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Yes
No
Did you have close contact with a person who has a probable or confirmed case of COVID-19?
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Yes
No
Severe difficulty breathing, shortness of breath at rest and/or severe chest pain?
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Yes
No
I hereby release my therapist, and the business at which they work from any and all liability for any unintentional exposure or harm due to COVID-19. I understand that my therapist and the business has improved and expanded their sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.
Submit
Should be Empty: