Before any service can be performed, we ask all customers to please fill out the form below and fill it out prior to arrival.  We thank you and look forward in seeing you soon.

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General & Medical Information

Are you in good health?
Has there been any change to your health in the past year?

If you answer "yes" to any of the following questions, please explain as clearly as possible in the space provided.

Do you suffer from acne?
Do you wear dentures?
Do you suffer from allergies?
Do you have a pacemaker?
Do you have arthritis?
Are you currently being treated by?
Do you have high blood pressure?
physicians for any condition?
Do you suffer from epilepsy or seizures?
Are you taking any medications (including non-prescription drugs)?
Do you suffer from claustrophobia?
Do you have varicose veins or distended capillaries?
Birth Control Pills
Do you have any contagious diseases?
Hormone Therapy
Do you have heart disease?
Do you have asthma?
Have you ever had surgery?
Have you ever had or currently have cancer?
Do you exercise regularly?
How would you describe your overall level of stress?
Do you suffer from a blood disorder?
What is your goal for this visit?
Do you have seborrhea?
Just a relaxing distress message Or membership package of
Are you pregnant or nursing?
Do you wear contact lenses?

Please take a moment to carefully read the following information you have provided and sign where indicated. If you have a specific medical condition or specific symptoms, certain massage or esthetic treatments may be contraindicated. A referral from your primary care provider may be required prior to services being rendered. If I experience any pain or discomfort during this session I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my comfort level. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
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