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
City
State / Province
Postal / Zip Code
Birthdate:
ex. 01/05/1960
What is the best way to contact you?
*
Phone call
Email
Text
All
How did you hear about me?
Instagram
Facebook
Google
Other
Did someone refer you?
Let me know who so I can thank them.
Please list any allergies you may have.
*
Have you experienced any recent abdominal surgery or injury?
NO
YES
Have you ever experienced an abdominal massage before?
*
NO
YES
Have you been diagnosed with any abdominal or pelvic conditions (hernias, ulcers, endometriosis or fibroids)?
YES
NO
Are you pregnant or trying to conceive?
YES
NO
Have you been diagnosed with any inflammatory diseases such as Crohns, Diverticulitis, or Colitis?
YES
NO
Is there anything else you would like me to know about your overall health or wellness that might be helpful for today’s session?
Do you follow a regular exercise program?
NO
YES
What is your current level of stress?
Low
Moderate
High
Preparing for your appointment
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.
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 bodywork professional from liability and assume full responsibility thereof.
*
I understand the cancellation policy.
Abdominal massage should be avoided if you have any of the following: Recent abdominal or pelvic surgery, active infections or inflammation, hernias, recent miscarriage or less than 6 weeks postpartum, severe bloating or GI bleeding.
*
I understand this 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
*
-
Month
-
Day
Year
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Signature
*
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