Spa & Aesthetics Initial Form

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Personal* This field is required.
First Name
Last Name
Date of Birth
Select One
Select One
Male
Female
Gender
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Full Name
Full Name
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Forms
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Contact* This field is required.
Email
Phone
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Address
Street Address
Address Line 2
City
State
Zip Code
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How did you hear about us?* This field is required.
Referral from Friend/Family
Suburban Essex
Other Magazine/Newspaper
Instagram
Facebook
Internet
Gym/Health Club
School Event
Other
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Who referred you?Please enter the name of the person who referred you to us.
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Other Referral SourcePlease describe how you first heard about us.
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Emergency Contact* This field is required.
Emergency Contact's Name
Emergency Contact's Phone Number
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Consent* This field is required.Agree to the statement by checking the box on the left side.
I request and consent to the performance of medical procedures, including, but not limited to, various types of massage, aromatherapy, facials, microdermabrasion, chemical peels, body treatments, fat freezing (cryolipolysis), Ultherapy®, NeoGraft®, microneedling, and platelet-rich plasma treatments, on me by the doctors, nurse practitioners, registered nurses, medical technicians, massage therapists, estheticians, and/or clinical staff of NJ Health Hub.
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Risks to Treatment* This field is required.Agree to the statement by checking the box on the left side.
I understand and am informed that in the performing of the aforementioned services, there are some risks to treatment including, but not limited to, redness and/or irritation of the skin, inflammation, soreness, bruising, numbness, swelling, pain, bleeding, feelings of lightheadedness, blood pressure changes, allergic reactions, and exacerbation of undiscovered injury.
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Informing the Service Provider* This field is required.Agree to the statement by checking the box on the left side.
I understand the importance of informing my service provider of all medical conditions and medications I am taking, and to let him/her know about any changes to these. I understand that there may be additional risks based on my physical condition.I also understand that it is my responsibility to inform my service provider of any discomfort I may feel during the treatment session so he/she can adjust accordingly.
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Judgment of Provider* This field is required.Agree to the statement by checking the box on the left side.
I do not expect the service provider to be able to anticipate and explain all risks and complications, and I wish to rely on the service provider to exercise judgment during the course of the procedure which the service provider feels at the time, based upon the facts then known, is in my best interests.
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Signature* This field is required.Whereas I have read and understand the foregoing, of my own free will and volition I choose to sign this acknowledgement, undergo treatment(s), and waive any claims against NJ Health Hub and its related clinical staff, employees, advisors, directors, and owners. By signing on the line below, I understand and agree that this electronic signature is the legal equivalent of my pen and paper signature.
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