2015-16 Complete Fitness & Spa Program

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SKIN CARE THERAPY PREFERENCES
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
WAXING
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
GENERAL 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.
SIGNATURE :
THERAPIST SPECIAL NOTES: