Organic Elements Spa Intake Form
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 service being provided.
If you answer “Yes” to any of the following questions, please explain as clearly as possible.
If Yes, please explain:
Read the following lists of health conditions carefully and mark each item either “Yes,” if you have that condition or “No,” if you do not.
Contraindications and Precautions: If you have any of the following conditions your therapist will customize your service to your specific needs:
Skin Care and Concerns for your Esthetician
These questions are to help your professional create your customized service with products to benefit you.
Please list any medications, skin care supplements or any treatments you have had that could make your skin more sensitive/reactive: (i.e.: Retin-A, Accutane, Vita, glycolic products chemical peel, Microdermabrasion, laser hair removal, any skin thinning products in the last 6 months
1. What is your skin type? Check all that apply.
2. What are your skin care concerns and/or what would you like to prevent: Check all that apply.
3. When was your last facial treatment?
4. What is your skincare routine at home? Check all that apply.
5. Do you prefer a foamy or milky cleanser?
6. Do you prefer a gentle or active exfoliant?
7. Do you prefer a matte, medium or dewy moisturizer?
8. Do you have any allergies?
Other Contraindications and Precautions: If you have any of the following conditions, you may not be able to receive microdermabrasion or peel treatments:
Are you allergic or sensitive to:
If yes, please explain:
I understand that these treatments may involve certain risks (including but not limited to: Soreness, swelling, redness, sensitive reaction) and I fully accept all responsibilities regarding the risks, and I release Dynatronics and Organic Elements Spa from any and all liabilities whatsoever.
I understand that I must remove my contact lenses prior to treatment.
I have reviewed the contraindications and I am not subject to any of those conditions.
I understand that the massage/bodywork/spa treatment I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the treatment, pressure and/or strokes may be adjusted to my level of comfort. 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 of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, 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. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
May I call you at your home, work or cell phone number to confirm future appointments? No Yes
May I contact you via mail/email about future promotions and news? No Yes
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Consent to Treatment of Minor: By my signature below, I hereby authorize Organic Elements Spa to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.