Facial Form NameStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeEmail AddressPhoneDateHow did you hear about us?List any medications, supplements, or herbal remedies you currently take:Please list allergies or sensitivities:Preferred Massage Pressure?What are your specific concerns at this time regarding your skin or body?What is your stress level right now?LowAverageSomewhat StressedVery StressedPlease list Injuries or surgeries:Have you ever received professional skin care treatments or massage?YesNoWhat do you consider your skin type? (For facials only)NormalOilyAcneDryAgeingCombinationSensetiveRosaceaOtherWhat is your daily skin care regimen? (For Facials Only)What is your goal for this session.Please check all that apply.*PregnantPostpartumNeck PainBack PainHeadachesHigh Blood PressureBruise EasilyDiabetesSeizuresKnee/Leg painJaw Pain / Clenching/ GrindingMetal ImplantsFibromyalgiaUsed Retin-A within the past 10 days?None of the aboveSubmit
