Treatment Intake Form

Personal Information
Name*
Email Address*
Phone Number*
Date of Birth*
Address*
City*
State*
Zip Code*
Occupation
Employer
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
Primary Care Physician
Primary Care Physician Phone
How did you hear about us?
Please fill in all required fields.
Medical Information
Are you taking any medications?*
Please list name of medications and their use:
Are you currently pregnant?*
What is your expected due date?
Any high risk factors?
Do you suffer from chronic pain?*
Please explain:
What makes it better?
What makes it worse?
Have you had orthoscopic surgery?*
Please list:
Please check any of the following that apply to you.
Please explain any conditions you checked.
Include approximate dates (if applicable)
Please fill in all required fields.
Treatment Information
Have you ever had a professional facial/massage before?*
What type of massage are you seeking?
Describe
What pressure do you prefer?
Do you have any allergies?*
Please explain.
Are there any areas that you don't want massaged?
What are your treatment goals for this treatment session?*
Please describe any areas of discomfort you are currently feeling.*
Please fill in all required fields.
Health
Within the past year, have you been under a dermatologist or other physician's care?*
Do you smoke?*
Do you exercise regularly?*
Do you follow a restricted diet?*
Do you wear contact lenses?*
Do you have metal implants, a pacemaker, or body piercings?*
If you answer "yes" to any of the above, please explain as clearly as possible.
Your Skin
Do you have any special skin problems pertaining to your body?*
Please explain.
What skin care products do you currently use on your face?
Check all that apply
What skin care products do you currently use on your body?
Check all that apply
Exfoliation History
Have you ever had a chemical peel, microdermabrasion, or any other resurfacing treatment?*
When?
Have you used Accutane, Retin A, Renova, Adapalene, Tazoorac in the past 3 months?*
Are you currently using any products that contain the following ingredients: Glycolic Acid, Lactic Acid, Exfoliating Scrub, Hydroxy Acid, Vitamin A derivatives (i.e. Retinol)?*
Hydration
How much plain water do you drink daily?*
How many alcoholic beverages do you consume on average?*
Do you experience any of the following conditions on your skin?
What SPF sunscreen do you use on your face?
What SPF sunscreen do you use on your body?
Capillary Activity
Do you burn easily in moderate sunlight?*
Do you blush easily when nervous?*
Do you have a tendency to have redness?*
Do you suffer from sinus problems?*
If you answer "yes" to any of the above, please explain as clearly as possible.
Oil Secretion
Do you ever experience oily shine during the day?*
Do you ever experience breakouts?*
If you answer "yes" to any of the above, please explain as clearly as possible.
Nerve Activity
What is your pain threshold?*
Have you ever experienced claustrophobia?*
Have you ever had a reaction to the following: Cosmetics, Medicine, Iodine, Pollen, Hydroxy, Acids, Animals, Fragrance, Suncreen, Latex, Other? Explain
What are your skin care goals?
Manicure / Pedicure
Any medical conditions/medications of which we need to be aware?
Color preferences?
Activities/Exercises that take a toll on your hands/feet?
Please fill in all required fields.
We care about your feet!
Do you experience dry skin on your feet?*
Do you experience cracked skin on your feet?*
Do you experience peeling skin on your feet?*
Do you experience itchiness on your feet?*
Do you experience skin fungus on your feet?*
Do you experience callus build up on your feet?*
Do you experience discolored nails on your feet?*
Do you experience thick nails on your feet?*
Do you experience nail fungus on your feet?*
Do you experience foot odor?*
Do you experience corns on your feet?*
Do you experience sweaty feet?*
Please fill in all required fields.
Waiver
I understand the treatment(s) I receive today are therapeutic and non-sexual. I understand my practitioner reserve the right to end a therapy session in the case of sexual innuendo or advance from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage and I will be liable for full payment of the scheduled session.
I understand the facial I receive today is provided for the basic purpose of relaxation and cleansing. If I experience any pain or comfort in this session, I will immediately inform the practitioner so that the pressure and/or products may be adjusted to my level of comfort. I further understand that facials should not be substituted for medical examination, diagnosis or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand practitioners are not qualified to diagnosis, prescribe, or treat any mental or physical illness and nothing said in course of session given should be construed as such. Since a facial should not be performed under certain medical conditions, I affirm I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as top any changes in my medical profile and understand any illicit or sexually aggressive remarks or advances made by me will result in immediate termination of the session and I will be liable for the payment of scheduled appt
Cancellation & Reschedule
You may cancel or reschedule an appointment with no charge giving us no less than 24 hours preceding your appointment. Same day cancellations or appointment changes may be charged 50% of the scheduled service price. If you do not cancel or show up, you may be charged full price.
By submitting this form, you agree to the terms & conditions state above
Cancellation Policy

Due to COVID-19, the amount of guests we are able to see in one day has been cut in half. Therefore, now more than ever, we ask that you please do your best to respect our time.*

Time is our most valuable asset. Your spa treatments are reserved just for you. We value your business and your time. If you need to cancel, please notify us at least 24 hours in advance. We do ask that you leave a credit card number on file with us when making your appointment. Any cancellations with less than 24 hours of notification WILL be charged in full for the scheduled service to the card on file. Guests who miss their appointments without giving any prior notification will be charged in full for the scheduled service to the card on file. When you miss an appointment with us, we not only lose your business, but also the potential business of other guests who could have scheduled an appointment for the same time. Late arrivals will receive the best treatment possible within the remaining appointment time; full service charges still apply. By booking an appointment with us, guests are agreeing to this policy.

Thank you for your understanding.
The Staff of Healing Hands Wellness Studio