Intake Form

PERSONAL INFORMATION

Your Name First and Last*

Your In Case of Emergency Contact Name/Phone/Relation*

MARKETING

How did you hear about us?*
GoogleFacebookInstagramReferralYelpOther

If Referral, Who?

CONCERNS

What are your specific concerns today?*

HISTORY

Have you ever had a professional...?* (check all that apply)*
FacialMassageManicurePedicureNone

Do you have any medically implanted devices that contain metal or electricity?*
YESNO

Have you ever had surgery?*
YESNO

If Yes, Please Explain and if you have any lasting ill effects.

What hair removal methods have you used in the last 6 weeks.*
WaxingThreadingTweezingLaserNone

SKIN AND ALLERGIES

Do you currently have any skin lesions or sores?*
YESNO

Have you ever had a nail infection or fungus?*
YESNO

Do you have an allergy to peanuts or peanut oil?*
YESNO

Do you have sensitivity to any plant based products?*
YESNO

If yes, Please Explain.

Have you ever had an allergic reaction to any of the following?*
CosmeticsMedicineFoodCinnamonAHA’sIodineNut and Nut OilsSunscreensFragranceFruits/VegetablesShellfishPlants/FlowersPollenOtherNone

If yes, please specify.

Are you exposed to the sun on a daily basis or are you planning to spend time in the sun soon?*
YESNO

Do you use a tanning bed?*
YESNO

List any medications that you are taking and the conditions that they are prescribed for:(if none, put N/A)

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*
YESNO

Are you using Retin-A, Renova, Accutane or other Acne medication?*
YESNO

Are you using any other skin thinning products or medications?*
YESNO

HEALTH CONCERNS

Do you have arthritis?*
YESNO

If yes, what areas are affected?

Do you have high blood pressure?*
YESNO

Are you Diabetic?*
YESNO

Do you have any known spinal problems?*
YESNO

If yes, Please Explain.

Have you had any recent injuries that we need to be aware of?*
YESNO

If yes, Please Explain.

Are you currently under care of another health care practitioner for this or any other condition?*
YESNO

If yes, Please Explain.

Are you experiencing any of the following?*
Leg CrampsNauseaIrregular BleedingHip PainSwelling/EdemaAcid RefluxHeadachesDizzinessLoss of Feeling/TinglingNone

SKIN CONCERNS & ROUTINES

What skin care steps are you currently doing?
CleanserTonerMaskSerumConcentrateEye CreamSPFExfoliationNight CreamLip CareAHARetinolNone

What areas of concern do you have regarding your skin overall?*
Breakouts/AcneUneven Skin ToneDull Dry SkinBlackheads/WhiteheadsSun DamageDehydrated SkinExcessive OilWrinkles/Fine LinesFlakey SkinRosaceaBroken CapillariesRedness/RuddinessSun Spot/Liver Spot/Brown SpotNone

EYES
DehydratedWrinklesPuffinessDark CirclesNone

LIPS
DehydratedChapped/Cracked LipsNone

REPRODUCTIVE HEALTH

Are you pregnant?*
YESNO

What is your due date?

How many weeks along?

Are you having any complications with this pregnancy?
YESNO

If yes, please explain.

Is this your first pregnancy?
YESNO

If you have had a miscarriage, when was it?

If you were able to determine the cause, please explain.

Are you currently breastfeeding?
YESNO

Payment is due in full at time of service.

We accept Cash, Check, Visa, MasterCard, Discover, and American Express, Spa Finder and Spa Wish.

Upon request, we can issue a receipt for you to submit for reimbursement from your insurance company. However, all claim submission and contact with the insurance company will be done through the patient as we are not an insurance provider.

If you are unable to make your scheduled appointment please provide 24 hours notice of cancellation. Failure to provide 24 hour notice may result in a fee of 50% of your scheduled appointment charge.

All appointments require a credit card number to confirm your reservation.

Any promotional flyers, coupons or gift certificates must be surrendered at time of service in order to receive credit.

No Children are permitted in spa unless receiving services.
By Checking this box, I understand and will comply with the above terms.

Treatment Purpose
I understand that spa services are for the purpose of relaxation, stress reduction, relief from muscular tension or spasm and for increasing circulation and energy flow as well as to promote healthy skin, nails and body care. I understand that the Technicians do not diagnose illness, disease or any other physical or mental disorder. As such, the Technicians do not prescribe medical treatment or pharmaceuticals nor is any spinal adjustment performed. I understand that the Technician may need to refer me to my physician for my safety.
By Checking this box, I certify that all the information provided is true and correct.

Your Behavior
I understand that illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and that I will be liable for payment of the scheduled appointment. Following such instance, I understand that I will not be permitted to receive any further treatments. If at any time during the session, your technician is uncomfortable, the session will also be terminated.
By Checking this box, I understand and will comply with the above terms.

Consent to Treat
I have read the above information and if I have any concerns, I will address these with my technician. I give permission to perform the procedure discussed and I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my technician will take every precaution to minimize or eliminate negative reactions as much as possible. I am willing to follow recommendation made by my technician for a home care regimen that can greatly increase my results. In the event that I have any additional questions or concerns regarding my treatment or suggested home product/Post-treatment care, I will consult the technician immediately. I agree that this constitutes full disclosure and that it superseded any previous verbal or written disclosures. I do not hold A Premier Massage & Day Spa or the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment today. I understand that if any of my information provided on this form changes it is my responsibility to notify my technician at the time of service.
By Checking this box, I understand and will comply with the above terms.

Your Name First and Last as your digital signature*