Facial Massage Form

Medical & Skin History

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Would you like to be added to my email newsletter?

Yes please.No thanks.
Phone:*
ex. 555-555-5555
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:
ex. 01/05/1960
What is the best way to contact you?*

Phone callEmailTextAll
How did you hear about me?

InstagramFacebookGoogleOther
Did someone refer you?
Let me know who so I can thank them.
Please list any allergies you may have or type NONE. *
Do you experience any discomfort or tension in your jaw, neck, or face?(e.g., TMJ, clenching, grinding, etc.)?

NOYES
Have you ever experienced a facial massage or intraoral massage before?*

NOYES
Do you have any medical conditions that affect your muscles, nerves, or connective tissues ( Bell’s palsy, fibromyalgia, trigeminal neuralgia)

YESNO
If you have had fillers, neurotoxin (botox etc.) or laser hair removal I suggest waiting two weeks before a facial massage. If you have had PDO thread the wait time is 60-90 days. Please consult with your injector or threading provider.

I understand
Are you currently undergoing any dental treatments or have any dental issues?(e.g., recent extractions, braces, dental work, etc.)

YESNO
Is there anything else you would like me to know about your overall health or wellness that might be helpful for today’s session?
Have you had any of these health conditions in the past or present?

CancerHormone imbalanceSystemic diseaseHigh blood pressureSpinal injuryThyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsyFever blistersHepatitisHerpesCold soresImmune disordersHIV/AIDSLupusMetal implantsPhlebitisBlood clotsInsomniaSeizure disorderKeloid scarringMigranesSkin diseaseActive Infection
Do you follow a regular exercise program?

NOYES
What is your current level of stress?

LowModerateHigh
Preparing for your appointment
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 Paz Amor Studio and/or the skin care professional from liability and assume full responsibility thereof.*

I understand the cancellation policy.
A credit card will be needed to secure your appointment. A 50% deposit will be requested at the time of booking and goes toward your treatment. This is non refundable. Please cancel or reschedule 24 hours prior to your appointment start time. If you need to reschedule, your deposit will carry over one time and you must book within 7 days. To cancel an appointment please contact Paz Amor Studio at least 24 hours prior to your appointment. If you are running late, you agree to communicate via text. You will still be required to pay the full price of the service and you may only receive the remaining time available. Please understand that there may be a client scheduled after you. 15 minutes late is considered a no show.*

I understand the cancellation policy.
OPTIONAL: I grant permission to Paz Amor Studio to use photos of my treatment for marketing purposes on www.Pazamorstudio.com or other business listing pages such as Instagram or Facebook.

I grant permission.No thank you.
Date*

MonthDayYear
Signature*
Should be Empty:

Medical & Skin History