Please enable JavaScript in your browser to complete this form. - Step 1 of 3Name *Birthday *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Occupation *Emergency Contact - Name *Emergency Contact - Phone *Would you like to be added to our email list for specials and discounts? *YesNoHow did you hear about us?NextMedical HistoryPlease check all that apply:AcneArthritisDepressionDiabetesEczemaEpilepsyFever BlistersHeart ConditionHepatitisHigh Blood PressureHIVHyper PigmentationHypo PigmentationInsomniaLow Blood PressureLupusSinus InfectionPregnantPsoriasisRashesSeborrheaShinglesSkin CancerHyper/Hypo ThyroidWartsFood sensitivitiesAnemiaKeloidsHerpesHepatitisAny SurgeriesAny other medical conditions other than aboveAre you currently taking any medications? *YesNoPlease explain the medicationsHave you been on Accutane? *Do you have any allergies? *YesNoPlease explain the allergiesSkin Care HistoryCheck the products that you currently useBody LotionBody SoapBody ScrubCleansing CreamDay CreamEye Makeup RemoverEye CreamExfoliatesFacial SoapFacial ScrubHand CreamNeck CreamNight CreamSkin Toner/AstringentPlease select all that applyMention any other products that you use other than the aboveWhat type of skin do you have? *NormalOilyDryCombinationUnsureConditions you are currently experiencing todayAnxietyFatigueForgetfulnessHeadacheInflammationInsomniaMuscle CrampsStressPlease select all that applyDo you have a family history of high level Fitzpatrick or a red head gene?Important InformationWhat concerns do you have regarding your skin?Acne/BreakoutsBlackheads/WhiteBroken CapillariesHeads Clogged PoresDark SpotsDrynessExcessive Oil/ShineRednessRosaceaSun DamageScarringUnwanted HairUneven Skin ToneWrinkles/Fine LinesPlease select all that applyAny other concerns regarding your skin, other than the aboveHave you had any facial or dermatology services in the past 30 days? *YesNoPlease explainHave you been under the care of a dermatologist within the past year? *YesNoPlease explainHave you used Retin-A, Renova, AHAs, Retinal/Vitamin A products in the last three months? *YesNoPlease explainHave you received Botox, Restylane, or Collagen injections in the last 6 months? *YesNoPlease explainPreviousNextDeclarationBy signing below, I agree to the following: I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I fully understand this agreement and all information detailed to me, including the procedure and risks. I will inform the esthetician/acupuncturist of any discomfort I experience during my treatment to allow them to adjust accordingly. I understand my home care instructions and if I have additional questions or concerns, I will consult the esthetician/acupuncturist. I agree to waive all liability toward my esthetician/acupuncturist and the clinic for any injury/damages incurred due to misrepresentation of my health. Signature *Date *24-Hour Cancellation PolicyWe understand that you may need to cancel or change your appointment. In order to maintain quality patient-centered care, we require a 24 hour cancellation notice when you are unable to keep your scheduled appointment; otherwise you will be charged full price of your appointment, minimally $95. For Rolfing, the first time fee is $200 (full price). Please note, insurance and third party coverage do not pay this fee. I have read and understand the above policy. Signature of the Patient *Date *COVID-19 PolicyAre you vaccinated? *Have you received a booster? *Vaccine typeDates of vaccination No clients will be treated in the clinic with any viral symptoms such as a fever, cough, or shortness of breath. Non-contact forehead thermometer reading will be taken prior to entrance to the clinic. Every client is required to wear a clean mask and use hand sanitizer. Proof of vaccination required for all clients unless your physician has advised against the vaccine due to a severely compromised immune system or you have had COVID-19 and still have high antibodies to your system or you can provide a covid-19 test within the last 24 hours. Non-vaccinated clients must provide a negative covid-19 test within 24 hours of entering the clinic. I have read and understand the above policy.Signature of the Patient *Date *PreviousSubmit
