Name
*
First Name
Last Name
Preferred Name:
Date of Birth
*
Birthday
MM
DD
YYYY
Preferred Pronouns (EX: She/Her)
Email
*
Phone
*
How did you hear about us?
Instagram
Google
Facebook
Friend/Family
Occupation
*
Are you currently under any medical care or have an injury we need to be aware of? Please describe
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Please list any allergies:
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Have you ever had complications during a massage, body treatment, facial, waxing or nail service?
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Please indicate if you have any medical conditions or communicable diseases:
*
Do you have foot fungus?
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Yes
No
Do you have athlete’s foot?
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Yes
No
Are you currently under the care of a podiatrist?
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Yes
No
If you are pregnant, how far along?
Have you ever had a professional massage, facial or body scrub/wrap?
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Yes
No
What type of massage pressure do you prefer?
*
Light
Medium
Deep
Are there any areas of your body you would like us to avoid?
*
To benefit the most from your treatment, please list areas or concerns you would like your spa provider to give attention to:
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What are your skin care concerns/sensitivities? Please list any doctor prescribed medications for skin. What products are you currently using?
If you are receiving a facial, please provide the most information you can.
If I am receiving an Advanced Facial or Skin Peel I understand:
I understand that results achieved may vary from person to person.
I understand that the number of treatments also vary from person to person.
I certify that I have not used Retin-A or Accutane in the last 6 months.
I understand proper home care after my service is required for optimal results and outcome.
I have consulted with the esthetician and all of my questions have been answered to my satisfaction. I understand the treatment and it is solely my decision to have this treatment
As A Guest Of Blooming Moon Spa:
*
I do not have any following symptoms: Fever / chills, cough, shortness of breath / difficulty breathing, fatigue, muscle / body aches, headache, new loss of taste / smell, sore throat, congestion / runny nose, nausea / vomiting, or diarrhea.