Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Birthday
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
How did you hear about us?
List any medications, supplements, or herbal remedies you currently take:
Please list allergies or sensitivities:
Preferred Massage Pressure?
What are your specific concerns at this time regarding your skin or body?
What is your stress level right now?
Low
Average
Somewhat Stressed
Very Stressed
Please list Injuries or surgeries:
Have you ever received professional skin care treatments?
Please Select
Yes
No
What do you consider your skin type?
Normal
Oily
Acne
Dry
Aging
Combination
Sensitive
Rosacea
Other
What is your daily skin care regimen? Please be specific.
What is your goal for this session.
Please check all that apply.
*
Pregnant
Postpartum
Neck Pain
Back Pain
Headaches
High Blood Pressure
Bruise Easily
Diabetes
Seizures
Knee/Leg Pain
Jaw Pain / Clenching/ Grinding
Metal Implants
Fibromyalgia
Used Retin -A within the past 10 days?
Non of the above
Do you have any active Cold Sores?
Yes
No
Signature
*
By SUBMITTING THIS FORM, you agree to the following:1) I give my permission to receive massage, facials or waxing services.2) I understand that therapeutic massage is not a substitute for traditional medicaltreatment or medications.3) I understand that the therapist or esthetician does not diagnose illnesses or injuries,or prescribe medications.4) I have clearance from my physician to receive facials and massage therapy.5) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:• Superficial bruising or redness• Short-term muscle soreness• Exacerbation of undiscovered injury I, therefore, release Blomkraft and the individual therapist or esthetician from all liability concerning these injuries that may occur during the massage session.6) I understand the importance of informing my therapist of all medicalconditions and medications I am taking, and to let the massage therapist knowabout any changes to these. I understand that there may be additional risksbased on my physical condition.7) I understand that it is my responsibility to inform my therapist or esthetician of anydiscomfort I may feel during the session so he/she may adjustaccordingly.8) I understand that I or the therapist may terminate the session at anytime.9) I have been given a chance to ask questions about the sessionand my questions have been answered.
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