Name(First/Last)     Appointment Date

Address   City   State   Zip

Phone     Date of Birth     Occupation

Email
May we add you to our birthdays and specials database? yesno

How did you hear about us? aquaobx.comGoogleTrip AdvisorYelpOther
Referred By:

Emergency Contact   E/C Phone

GENERAL HEALTH

Do you smoke? noyes

Please list any medications you are taking

Are you currently under medical supervision? yesno
If yes, please explain

Please let us know of any medical conditions or health issues we should know about

Please list any allergies you have

Do you have any skin sensitivities or irritations? yesno
If yes, please explain

SKIN CARE & WAXING

Are you currently using?
AccutaneRetin ARenovaAdapaleneGlycolic AcidLactic AcidHydroxy AcidVitamin A
Have you ever had?
Chemical PeelMicrodermabrasionBotoxOther resurfacing
What is your main concern?
Sun DamageAcneLines & WrinklesScarring/TextureBlackheadsDiscolorationOther
What is your skin type?
Oily/CongestedDry/DehydratedAcneSensitive/RednessEczemaPsoriasisRosacea
Please describe your skin care goals

MASSAGE THERAPY

Have you ever had a professional massage before? noyes   If yes, when?
Goal for your massage RelaxationPain ReliefStress Reduction
If pain relief, please explain

It is my choice to receive spa therapies. I have completed this form to the best of my knowledge. I affirm that I have stated all known medical conditions including all known allergies or prescription drugs or products I am currently using. I agree to update AQUA Spa of any changes to my medical profile and understand there shall be no liability on the esthetician/therapist part should I fail to do so. I understand that Estheticians and Massage Therapists do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals, or perform spinal manipulations. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that is recommended I see a primary health care provider for that service. If I experience any pain or discomfort during my session I will immediately inform my esthetician/therapist. I give my permission to my esthetician/therapist to perform the procedures we have discussed and will hold them and AQUA Spa harmless from any liability that may result from this treatment. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my esthetician/therapist immediately.

Electronic Signature     Date

CONSENT TO TREATMENT OF A MINOR: By my signature below, I hereby authorize AQUA Spa's practitioner to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.

Signature of Parent or Guardian     Date

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