Facial Intake Form

Name*
First Last
DOB*
Month
Day
Year
Phone*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
How did you hear about us?*
- TripAdvisor
- Yelp
- Google Search
- Someone Referred Me
- I Received a Gift Certificate
Referred By Name*
Name
Tell us who we should send a thank you note.
Emergency contact name:
Name
Emergency contact phone
Occupation
Gender*
- Male
- Female
Enter your wedding date If you would like us to remind your husband of your wedding anniversary with a spa treatment.
Enter your wedding date if you want to receive special offer from diVINE SPA.
Wedding Date
Month
Day
Year
Are you pregnant or trying to become pregnant?*
- YES
- NO
Pregnancy Release Form

There are several observed or identified potential benefits to massage therapy during pregnancy including:

• Relieves muscular tension, especially in the lower back, upper back, shoulders and neck

• Reduces stress on weight-bearing joints

• Enhances body awareness for better posture and less discomfort

• Assists with body mechanics and movement during structural change

• Supports birth process by relaxing muscles involved in labor an birth

• Eases anxiety and stress during time of transition

• Provides emotional support and nurturance

Prenatal Massage Therapy Contraindications

Performing massage therapy during pregnancy is contraindicated for women experiencing any of the following symptoms/signs:

• Bloody discharge

• Continual abdominal pains

• Sudden gush or leakage of amniotic fluid

• Sudden, rapid weight gain

• Increased blood pressure

• Protein or sugar in urine

• Severe back pain that does not subside with the change in position

• Visual disturbances

• Severe nausea and /or vomiting

• Severe headaches

• Excessive hunger and thirst

• Increased urination in the second trimester

• Fever

• Diarrhea

• Excessive swelling in our arms or legs

• A decrease in fetal movement over a twenty-four hour period

Some additional conditions that contraindicate massage therapy are any phlebitis, thrombosis, or suspected clotting conditions, any kidney, liver or spleen compromise or infection. Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.

Prenatal High Risk Pregnancies

It is a strict policy of diVINE SPA to require a signed doctor's release form in order for the client to receive massage therapy services if a client has a high risk pregnancy. High risk pregnancies include, but are not limited to:

1.) Early labor, miscarriage threat, placental or cervical dysfunction;

2.) Gestational Edema Proteinuria Hypertension (GEPH);

3.) Preeclampsia;

4.) Gestational Diabetes;

5.) Pre-existing cardiac, renal, connective tissues or liver disorders/diseases;

6.) Fetal genetic disorders;

7.) Complications in previous pregnancies;

8.) Three or more miscarriages

I have received and read the written information about the benefits and possible contraindications of massage therapy during pregnancy. I understand the information and confirm that:

• I have not experienced any of the complications listed on the sheet below;

• I have not experienced any of the conditions listed, which would make it unwise to have
massage therapy;
• I am experiencing a low-risk pregnancy;

• I am receiving medical care including regular check-ups throughout my pregnancy.

I understand that I will be receiving massage therapy as a form of adjunctive health care only and that this therapy is not intended to replace appropriate medical care.

Having been fully advised of the risks, contraindications, and complications to massage therapy during pregnancy, I have decided to participate in the therapy. Accordingly, I do forever release the practitioners and their insurers, and their respective officers, directors, stockholders, successors, employees and agents from all liability of any nature whatsoever, whether past, present, or future for injury or damage which may occur to myself or my family as a result of my receiving massage therapy during this childbearing year.

I further agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal or administrative action that has arisen or may arise directly from my and my child's participation in this therapy.
I consent to the pre-natal facial therapy and treatment*
- I AGREE TO THE PREGNANCY RELEASE FORM
Please read the consent form
Are you undergoing any contraceptives or hormone replacement therapy?*
- YES
- NO
What would you like to achieve from your treatment today?*
Are you currently taking any medications?*
- YES
- NO
Specify Medications*
Your Skincare
Have you ever had a facial treatment before?*
- YES
- NO
I received my last Facial Treatment*
- A Week Ago
- Less Than 3 Weeks Ago
- Less Than 1 Month Ago
- In the Last 3 Months
- In the Last 6 Months
- In the Last Year
- More Than a Year Ago
Do you have any skin or other allergies or sensitivity?*
- YES
- NO
Specify any allergies or sensitivity*
Do you have any special skin problems or concerns pertaining to your face?*
- YES
- NO
Specify skin problems / concerns about your face*
What areas of concern do you have regarding your skin?*
- Breakouts / ACNE
- Uneven Skin Tone
- Blackheads / Whiteheads
- Sun Damage
- Excessive Oil / Shine
- Wrinkles / Fine Lines
- Rosacea
- Dull / Dry Skin
- Broken Capillaries
- Flaky Skin
- Redness / Ruddiness
- Dehydrated
- Sun / Liver or Brown Spot
- Other
(Please check any that apply and explain)
Please specify other areas of concern*
Do you take or use any products that contain the following*
- Isotretinoin
- Tetracycline
- Retinoic Acid
- AHA Glycolic Acid
- Hydroquinone
- Ibuprofen (Advil)
- None
(Please select all that apply)
Do you use an ACNE Medication?*
- YES
- NO
Which ACNE Medication do you use?*
Did you recently have any type of chemical or glycolic peel?*
- YES
- NO
What kind of chemical or glycolic peel did you have?*
Any recent surgery, laser, wax or microdermabrasion?*
- YES
- NO
Please describe any recent surgery, laser, wax or microdermabrasion*
Any skin cancer or removal of skin cancer?*
- YES
- NO
Please describe any skin cancer or removal of skin cancer*
Have you been exposed to any tanning method in the past 24 hours?*
- YES
- NO
Please describe the tanning method you were exposed to*
Are there any other medical conditions I should know about?
Please describe
I consent to facial therapy and treatment*
- I AGREE TO THE FACIAL RELEASE FORM
Please read the consent form
Facial Release Form

I understand that anytime the skin barrier is compromised, there is a small risk of infection. I will contact my beauty therapist immediately should this happen. I understand that following the treatment my skin may appear red and feel like it has a slight sunburn.

Possible side effects include and are not limited to: slight or extreme redness, swelling, stinging, itchy, tenderness, dry or flaking skin. I understand that I am not to pick the flaking skin as could cause unwanted pigmentation. Most side effects will gradually diminish over time as healing may take several days or longer.

I understand that no specific results are guaranteed. Prior to receiving this treatment, I have been candid in revealing any condition that may have a bearing on this procedure (i.e. PREGNANCY, hormone replacement therapy, lactating, recent surgery, Botox, filler injections (collagen and others), Micro-pigmentation, Microdermabrasion, allergies, tendency to cold sores/fever blisters (Herpes Simplex), use of Retin-A, Renova, Differin, Accutane, any topical Alpha Hydroxy (AHA) or Beta Hydroxy (BHA-Salicylic) Acids, any oral contraceptives/hormone replacement therapy (HRT), or anti-coagulants (blood thinners), diabetes, radioactive or chemotherapy treatments, products that contain Isotretinoin, Tetracycline, Retinoic Acid, Hydroquinone, sunburn, windburn or broken skin, any method of hair removal on treated areas, history of keloidal scarring, any immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

I understand that there may be some degree of minor discomfort (i.e. stinging, pinpricking sensation, hotness, tightness, burning or itching, and that frosting, scabbing, swelling, and crusting are all common during healing.

I clearly understand and have been informed that any sun exposure following this treatment can result in hypo/hyper pigmentation of my skin and the use of sunscreen is mandatory.

I understand, have read and completed this questionnaire truthfully. I have been candid in revealing any conditions that could prohibit treatment(s), such as cold sores, use of hormones, recent facial surgery or laser resurfacing, recent use of Retin A or use of Accutane within last 18 months. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.

I acknowledge that the possibility of an adverse reaction to a facial occurs and that this is the case regardless of precautions taken. I accept whole responsibility for the treatment(s) I receive and for any medical care that may become necessary. I will immediately contact the Esthetician who performed the treatment of any adverse reaction. In the event that I can’t reach such person, I will immediately seek a medical care.

I agree that my participation in treatment(s) is voluntary and I accept the inherent risks. I fully understand that My Body TLC (diVINE spa) and its agents may refuse to perform a treatment(s).

I hereby release My Body TLC (diVINE spa), its agents, owner(s), employees, successors assigns, and suppliers from any and all damage or injury that may result from the treatment I receive. I represent that all the information provided by me has been true and correct and I am over the age 18 years old. I hereby authorize the therapist to perform said treatment(s).

I hereby agree to all the above and to have this treatment performed on me and to follow all recommendations and prescribed directions by my therapist regarding post peel care that can minimize or eliminate possible negative reactions and maximize positive results.
Clients Signature*
Date*
MM slash DD slash YYYY
Are you under 18 years of age?*
- YES
- NO
Parent or Guardian's Signature*

Facial Intake Form

Your Skincare

Facial Release Form