Consultation/Intake Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date of Birth

Date

How did you hear about us?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

What are your specific concerns at this time regarding your skin or body?

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If comfortable, please upload a picture of any areas of concern with your skin.

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Please list Injuries or surgeries:

Have you ever received professional skin care treatments, waxing, or massage?

What is your daily skin care regimen? (If you don't have one yet, enter "N/A")

What is your goal for your skin?

What kind of music do you prefer to listen to?

Do you prefer…

Do you have any questions regarding my services & products?

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive massage, facials, waxing or detoxing services.
2) I understand that therapeutic massage is not a substitute for traditional medical
treatment or medications.
3) I understand that the Skin Care Specialist does not diagnose illnesses or injuries, or prescribe medications.
4) I have clearance from my physician to receive facials, waxing and massage therapy.
5) I understand the risks associated with massage therapy, facials, waxing, and detoxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Organic Divinity LLC and the individual Skin Care Specialist from all liability concerning these injuries that may occur during the massage session.
6) I understand the importance of informing my Skin Care Specialist of all medical conditions and medications I am taking, and to let them know about any changes to these. I understand that there may be additional risks based on my physical condition.
7) I understand that it is my responsibility to inform my Skin Care Specialist of any discomfort I may feel/experience during the session so he may adjust accordingly.
8) I understand that I or the Skin Care Specialist may terminate the session at any time.
9) I have been given a chance to ask questions about the session and my questions have been answered.

10) I understand that there is a Zero-Guest policy.