The Retreat

Name *

First Name

Last Name

Mobile Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

In case of emergency: *

Name to notify

First Name

Last Name

In case of emergency: *

phone to notify

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How did your hear about us? *

Friend, family or direct referral

Google/Internet

Yelp

Facebook or Instagram

Other/don't recall

Are you on hormone therapy? *

YES

NO

Birthday *

We send out monthly BIRTHDAY specials!!!

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DD

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AGE: *

Under 21

21-30

31-40

41-50

Over 50

Have you used any of the following in the last month? *

Retrinoic Acid

Glycolic/ Saliclylic Acid

Hydroquinone

Are you pregnant or lactating? *

YES

NO

Are you on hormone therapy? *

YES

NO

Are you on birth control pills? *

YES

NO

Do you have a history of sun allergies? *

YES

NO

Have you ever had a skin allergy to a cometic product or skin care product? *

YES

NO

Do you have a history of allergic reactions to chemical peels? *

YES

NO

With sun exposure does you skin? *

Always burn

Usually burn

Rarely burn

Never burn

Do you have brown spots? *

YES

NO

Do you have a history of acne or periodic breakouts? *

YES

NO

If yes, please indicate all that apply:

Pimples

Whiteheads

Blackheads

Cysts

Pustules

Are you on any medication to control acne? *

Yes

NO

Does your skin ever flake or feel tight and dry? *

Frequently

Occasionally

Rarely

How soon after you cleanse do you begin to see shine on your face? *

15-60 minutes

1-3 hours

4+ hours

Have you recently had Botox, laser resurfacing or cosmetic surgery? *

YES

NO

Does your skin heal quickly? *

YES

NO

Do you form thick or raised scarring (keloid) from a cut or bruise *

YES

NO

Do you wax or use depilatories on your face? *

YES

NO

Do you ever get cold sores? *

YES

NO

I have completed this information form to the best of my knowledge, and I give my consent to receive treatment. I understand that massage therapists are not trained in the diagnosis and treatment of disease. Massage services are designed to be a health aid and are in no way to take the place of a doctor’s care when its is indicated. Because a massage therapist must be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health. I understand that any remarks or actions of a sexual or personal nature will result in immediate terminations of the session and that no future appointments allowed. *

This is your consent for treatment

YES - I give my consent.

No - I decline my consent.

Today's Date *

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