2015-16 Complete Fitness & Spa Program

S KIN C ARE T HERAPY P REFERENCES Please indicate your areas of concerns. Please check all that apply:  Skin Tone  Fine Lines - Skin Tone / Texture  Dehydration  Excessive Oil  Redness, Sensitivity  Clogged Pores, Acne  Eyes – Fine Lines, Puffiness  Lips – Fine Lines Are you sensitive to touch or pressure? Yes No

How often do you receive facial services?

Do you have a specific area you want focused on?

Do you use Retin-A, retinol, Renova or glycolic products? Yes No

Do you have any allergies?

Yes No

Have you received any injections, fillers or chemical peels? Yes No W AXING Have you ever been waxed before? Yes No

Rate your sensitivity to pain. Low Medium

High

Do you use Retin-A, retinol, Renova or glycolic products? Yes No

Do you use/take Tetracycline, Accutane , Salicylic Acid ?

Yes No

Do you use brown spot or skin lighteners for your skin?

Yes No

G ENERAL W ELLNESS INFORMATION Are you taking any medications regularly? Please list them.

Do you have any medical issues? Please list them.

I understand that massage, skin, nail and bodywork I receive are provided for the basic purpose of relaxation and / or relief of muscular tension. 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 level of comfort. If I feel the service needs to be discontinued for any reason I affirm I will communicate to the practitioner to act in accordance. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.

S IGNATURE : T HERAPIST S PECIAL NOTES :