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Name: ___________________________________________________________________________ Address: _________________________________________________________________________ Phone Number: ______________________________ Cel Number: __________________________ Email: ___________________________________________________________________________ Date of Birth: ______________________________________________________________________ Referred by: ______________________________________________________________________

Contraindications: (tick where appropriate) Any form of infection, disease or fever Cancer Hypersensitive skin High Blood Pressure Epilepsy Recent surgery (last 5 years) Diabetes Varicose Veins Bruise Easily Pacemaker/Metal Implants Allergies HIV/Hepatitis Arthritis/Joint Pain Pregnancy Have you had chemical peels, laser, microdermabrasion or any resurfacing treatments? Yes Do you use Accutane, Retin A, Renova, Salicylic Acid; Beta/Alpha Hydroxyacids? Yes No No

If you have checked any of the above, please explain: _____________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

For all waxing services please note that, for best results, the area should not have been shaved or waxed for at least 3 weeks prior to your appointment. I understand that the massage and facial services I receive are provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I further understand that the massage/facial should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because certain spa treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so. I also understand that the Certified Esthetician reserves the right to refuse to perform treatments on anyone whom she deems to have a condition for which facial, massage or waxing treatments are contraindicated. This information is confidential and will not be passed onto a third party. Please sign below to confirm that all information is, as of date, accurate.

X ____________________________________________ Date _______________________________


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