Microsoft word - bliss_client_intake_form.reviseddoc.doc

The following questionnaire provides the information that will enable us to provide you services a treatments safely and effectively. All information is completely confidential, and vital for your protection as well as ours. Thank you for your cooperation. First Name:_________________________ Middle:_______________ Last:______________________________
Address:_______________________________________ City:__________________ State:______ Zip:________
Home Phone: ______________________ Cell Phone: ___________________ Work Phone:_________________
Birthday: _____________________ Age:________ Anniversary, if married:______________________________
Email:___________________________________ Would you like to receive specials by email?_____________
Occupation:__________________________________ Referred By:____________________________________
MEDICAL HISTORY:
Please list all medication you take internally/topically:_______________________________________________
Do you have health problems? (Please check all that apply currently or in your past)
___ Allergies
___ Cancer/Cancer Therapy ___ Headaches ___ Back/neck pain ___ Pregnant/Lactating *NEEDS PRENATAL FORM* Please explain any checked above: _____________________________________________________________ Do you have any other Medical Conditions we need to be aware of? ____________________________________ Have you ever experienced an allergic reaction to any drug or other substance? (If yes, please explain): ________
SKIN CARE AND WAXING:
What skin care line are you using? _______________ Do you wear makeup?______ What brand?_____________
Please explain how you take care of your skin daily/nightly: __________________________________________
Have you ever had an allergic reaction to a cosmetic product? (If yes, please explain):______________________________
Please circle the skincare products you are currently using at home:
Cleanser
Please circle if you are using or have used any of the following: Benzoyl Peroxide (BP) Please circle if you have been prescribed the following products: Tretinoin (Retin A, Retin-A Micro, Renova , Avita) Other:_____________________________________________________ What skin conditions do you want to improve? (Please circle all that apply) Acne and/or Breakouts Rosacea Facial Scarring Uneven Tone Hyperpigmentation (Freckles, Age Spots) Enlarged Pores Dehydration Uneven Texture Oily
Fine Lines and Wrinkles Other:____________________________________________________________
NAILS:
How often do you get nail services? ____________________ What do you want out of the service? __________________
Please circle if you have any of the following:
Athletes Foot

Are you allergic to Phameldahyde, Toleen, or Coleen? ______ Where are your problem areas? _______________________
MASSAGE THERAPY:
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms,
massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to providing service.
Have you ever experienced a professional massage or bodywork session? __________ How recently?__________
If yes, what did you like about it? ________________________ What didn’t you like? _____________________
What type of pressure do you prefer? __________________________ *Deep Tissue is an additional fee*
Have you been in an accident or suffered any injuries? (If yes, please explain): ____________________________
___________________________________________________________________________________________
Do you have tingling or numbness in a specific area? (If yes, please explain): _____________________________
Areas of the body to administer additional Massage Therapy: __________________________________________
Areas to be avoided: ________________________________ Reason: ___________________________________
Appropriate draping will be used at all times. At any point a guest is uncomfortable, they may request to stop the service.
I, the client, understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. I further understand that
massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other
qualified medical specialist for any mental or physical ailment that I am aware of. In consideration of using the spa facilities and/or taking part in spa treatments/programs,
I agree, to the fullest extent permitted by law, to forever release, indemnify, defend and hold harmless the spa, it’s subsidiaries and affiliates, their respective agents,
officers, directors, owners, contractors and employees (collectively the “Released Parties”) from any and all claims and causes of action which I (or the below-mentioned
minor) might otherwise have or be entitled to assert as a result of or related to any physical injury or otherwise, including without limitations to death pr property damage
or loss sustained in connection with my use (or the below mentioned minor’s use) of the spa facilities, or participation in any spa program or treatment, including, without
limitation, claims and causes of action based on negligence, breach of warranty or breach of contract. I also agree to indemnify, defend, and hold harmless the Released
Parties from any and all claims brought by the third parties arising out of any (or the below-mentioned minor’s) acts, errors, or omissions.
Client Signature:______________________________________________ Date: __________________________
Consent to Treatment of Minor Under the Age of 17: By my signature below, I hereby authorize a Registered Licensed Massage Therapist to administer massage or
bodywork therapy techniques to my child or dependent as they deem necessary.
Guardian Signature: ____________________________________________ Date: _______________________

Source: http://blisssalon.info/Bliss_client_intake_form.reviseddoc.pdf