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| Spa Consultation Form |
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The information you provide on this form is confidential. We do not share information with any third parties. We use this information to help give you the best result during your visits with us. Please be as accurate as possible and help us give you the results you really want. |
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| Contact Info |
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| General Health Record |
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| Do you currently have any of the following skin conditions? |
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| When expsoed to the sun, do you? |
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| Do you currently have any of the following muscular-skeletal conditions? |
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| Do you currently have any of the following circulatory system conditions? |
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| Do you currently have any of the following respiratory system conditions? |
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| Do you currently have any of the following eye, ear, nose, or throat conditions? |
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| Do you currently have any of the following digestive system conditions? |
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| Do you currently have any of the following neurological conditions? |
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| Do you currently have any of the following reproductive system conditions? |
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| Have you ever been diagnosed with any of the following? |
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| Please list all known allergies you have below: |
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| Prescription Medications, Herbs, Vitamins (Internal and External): |
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| Are you coping with any of the following? |
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| Which of the following have had an impact on you in the last 12 months? |
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| What stress reducing activities do you do? |
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| Massage Therapy |
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| How often do you receive a massage? |
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| What massage pressure do you prefer? |
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| Prioritize the areas of your body to focus on during your massage: |
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| Describe all past, present, and ongoing injuries including breaks, sprains, strains surgeries and accidents: |
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| What results do you want from your massage session(s)? |
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| Facial Therapy |
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| How often do you receive a facial? |
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| What skin type/types do you have? |
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| What are your present facial skincare concerns? |
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| Do you have any of the following concerns in your eye area? |
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| Do you have any of the following concerns in your mouth area? |
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| Do you have any of the following concerns in your cheek area? |
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| Do you have any of the following concerns in your neck and decollete area? |
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| Have you recently received any of the following spa services? |
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| Have you received any of the following medical or surgical procedures? |
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| Do you use any of the following skin care products? |
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| Have you ever been prescribed Accutane? |
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| What improvements and results do you want from your facial? |
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| Body Therapy |
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| How often do you receive body therapies? |
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| Please indicate areas on your body with dry/flaky skin: |
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| Please indicate areas on your body that are oily or breakout: |
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| Please indicate areas on your body with a loss of elasticity and firmness: |
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| Please identify areas on your body you have cellulite concerns: |
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| Have you ever received any of the following surgical procedures? |
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| Do you use any of the following body products? |
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| What, if anything, would you like to improve about your body? |
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| Waxing Hair Removal |
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| How often do you receive waxing hair removal? |
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| Do you have a full three weeks worth of hair growth in the areas to be waxed? |
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| What areas of waxing hair removal interest you? |
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| You must be off the following prescription medications, as described below, for your waxing hair removal services to be safe for your body. |
1. Accutane -- Off 90 Days
2. Retin-A -- Off 5 To 7 Days
3. Retin-A Micro -- Off 5 To 7 Days
4. Renova -- Off 5 To 7 Days
5. Metrogel Cream/Lotion -- Off 5 To 7 Days
6. Differin -- Off 5 To 7 Days
7. Tazorec -- Off 5 To 7 Days
8. Plexion -- Off 5 To 7 Days
9. Avage -- Off 5 To 7 Days
10. Obagi -- Off 7 Days
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| Do you use skin care products that contain glycolic acid or get frequent glycolic acid treatments? |
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| If you haven't already done so, please list all oral and topical prescriptions: |
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| Have you ever been diagnosed with any of the following? |
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| What results do you want from your waxing services? |
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| PRODUCT INTERESTS |
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| Most of you are so used to buying personal care products that don't give you a result that you would never expect that there are products that exist to help make you healthier and look and feel better. Well, we have them and we want to help you look and feel your best. Please indicate which health and wellness product areas interest you. |
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| SPECIAL INTERESTS |
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| What, if any, groups, organizations, special interests, or causes are you a part of in your community? (From time to time we may like to support your group, organization, or area of interest by providing special offers exclusive only to your group. |
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| Briefly describe your role in your group, organization, special interest, or cause below: |
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