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Rejuvenation Spa Intake Forms/ Waiver/ Cancellation Policy

Medical History and Goals

First Member Name

First Name*

Last Name*
First Member Date of Birth*
I certify that I am 18 years of age or older
First Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
First Member Signature*
Second Member Name

First Name*

Last Name*
Second Member Date of Birth*
Second Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Third Member Name

First Name*

Last Name*
Third Member Date of Birth*
Third Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Fourth Member Name

First Name*

Last Name*
Fourth Member Date of Birth*
Fourth Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Fifth Member Name

First Name*

Last Name*
Fifth Member Date of Birth*
Fifth Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Sixth Member Name

First Name*

Last Name*
Sixth Member Date of Birth*
Sixth Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Seventh Member Name

First Name*

Last Name*
Seventh Member Date of Birth*
Seventh Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Eighth Member Name

First Name*

Last Name*
Eighth Member Date of Birth*
Eighth Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Ninth Member Name

First Name*

Last Name*
Ninth Member Date of Birth*
Ninth Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Tenth Member Name

First Name*

Last Name*
Tenth Member Date of Birth*
Tenth Member History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's History

Facial Intake Form


What is your present skin care regimen?

What conditions would you like to improve?

Are you under treatment for any current skin condition?

Do you take any medications/hormone replacement/vitamins for your skin?

Have you ever had a reaction to skincare products/ cosmetics/ medications/ fragrances? Which ones?
Do you suffer from any of the following?
Acne
Ezcema
Hormone imbalances
Psoriasis
Sensitive skin
None

Anything else you would like your esthetician to know?

Massage Intake Form

What type of massage are you seeking?*
Relaxing
Therapeutic/ Deep Tissue
Are you currently pregnant?*
No
Yes

Do you suffer from chronic pain? If so, explain.

Do you have any medical issues that may be relevant to your massage therapist? Example- blood clots, fibromyalgia, joint replacement, etc. If yes, please explain. *

Do you have any allergies or sensitivities to any fragrances, lotions, oils, etc.?

What is your goal from this treatment session?

Anything else you would like your massage therapist to know?

Infrared Sauna

The following are contraindications for the Infrared Sauna. If you suffer from ANY of these conditions, please contact your medical provider prior to your appointment.
Alcohol/ Alcohol abuse
Cardiovascular conditions
Chronic conditions
Fever
Hemophilia
Metal or any other surgical implants
Pregnancy
Taking medication
None
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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