Graceful_Lift_Connective_Tissue_Intake

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If you have had recent facial injectables/fillers/Botox, you will need to wait 6 weeks before utilizing Connective Tissue facial massage. Please reach out if you have any questions or concerns. Thank you!
Graceful Lift Connective Tissue Intake Form

(Confidential Client Information)
Full Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name & Phone
Format: (000) 000-0000.
1. Do you currently have or have a history of any of the following conditions:? (Check all that apply)
Other
Are you currently under medical care for any condition above?
If yes please explain
2. Do you experience frequent headaches or migraines?
3. Do you have chronic tension/pain in your face, neck, or jaw?
If yes please describe
4. Have you had facial connective tissue therapies before?
If yes when was your last treatment
5. How would you describe your skin type?
6. What skin concerns would you like to address?
7. Any known allergies or product sensitivities
8. Current skincare routine products frequency
9. Do you smoke or use tobacco products?
10. Do you drink at least 50% of your body weight in ounces of water daily?
11. How would you describe your stress levels?
12. What are your expectations for this treatment
- I understand that connective tissue treatments are intended to support overall skin wellness and circulation and are not a substitute for medical care.

- I have disclosed all relevant medical and health information to the best of my knowledge.

- I will communicate with my practitioner about any discomfort during the session.

- I understand that individual results vary and multiple sessions may be recommended.
Signature
Should be Empty:

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