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. Name:(Required) Cell phone:(Required)Date of Birth:(Required) MM slash DD slash YYYY Email:(Required) Referred by: General & Medical InformationOccupation: Height: Weight: FM Add RemoveAre you in good health? Yes No Age: Has there been any change to your health in the past year? Yes No If so, please explain: Physician: 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? Yes No Do you wear dentures? Yes No Do you suffer from allergies? Yes No Do you have a pacemaker? Yes No Do you have arthritis? Yes No Are you currently being treated by? Yes No Do you have high blood pressure? Yes No physicians for any condition? Yes No If yes, what medication are you taking? Please Explain Do you have any other medical condition I should know about? Do you suffer from epilepsy or seizures? Yes No Are you taking any medications (including non-prescription drugs)? Yes No Do you suffer from claustrophobia? Yes No Do you have varicose veins or distended capillaries? Yes No Birth Control Pills Yes No Diuretics Yes No Do you have any contagious diseases? Yes No Hormone Therapy Yes No Vitamins/Supplements Yes No Do you have heart disease? Yes No How much water do you drink a day? Do you have asthma? Yes No Have you ever had surgery? Yes No Have you ever had or currently have cancer? Yes No Do you exercise regularly? Yes No Please explain: How would you describe your overall level of stress? Low Medium High Do you suffer from a blood disorder? Yes No What is your goal for this visit? A monthly or by monthly massage visit Do you have seborrhea? Yes No Please explain: Just a relaxing distress message Or membership package of 6 12 Are you pregnant or nursing? yes No Do you wear contact lenses? Yes No 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. Client Signature: Date: MM slash DD slash YYYY Practitioner Signature: Date: MM slash DD slash YYYY CAPTCHA