Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Date of Birth

Date

Address

Street Address

CityState

Zip Code

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?

Please list Injuries or surgeries:

Have you ever received professional skin care treatments or massage?

What do you consider your skin type? (For facials only)

What is your daily skin care regimen? (For Facials Only)

What is your goal for this session.

Please check all that apply.

By submitting this form, you agree to the following:

I give my permission to receive massage, facials or waxing services.
I understand that therapeutic massage is not a substitute for traditional medical
treatment or medications.
I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications.
I have clearance from my physician to receive facials and massage therapy.
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 understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the esthetician know about any changes to these. I understand that there may be additional risks based on my physical condition.
I understand that it is my responsibility to inform my therapist or esthetician of any
discomfort I may feel during the session so she may adjust accordingly.
I understand that I or the therapist may terminate the session at any
time.
I have been given a chance to ask questions about the session
and my questions have been answered.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

I agree to above terms.

We would like your permission to use your photo for advertising and or social media. Your consent is necessary to do so. I herby give my permission A: to use, re-use, publish any photographic portraits or pictures of me. B: I relinquish any right that I may have to examine or approve the completed product or products advertising copy or printed matter that may be used in conjunction therewith or the use to which it may be applied. C: I hereby affirm that I am over the age of 18 and have the right to contract in my own name. I have read the above authorization, release and agreement, prior to this execution; I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives and assigns.

Date of Waiver Signed

Date

Signature

Facial Intake Form

Liability Waiver

Photo Release Agreement