Simply Amazing Spa llc Client Information
Last Name: ____________________________ First Name: ___________________Birthday _____________
Address: ____________________________________________ City_______________ Zip_______________
Phone Number: Cell _________________________ Home/Work/Other_______________________________
Email address: _____________________________________________________________________________
Prefer Method of Contact for appointment confirmation, follow ups, event invites, monthly specials, etc:
Phone Call
Text
Email
USPS
Occupation_____________ Emergency Contact___________________________Phone_________________
How did you hear about us?_____________________________ Reffered by: _________________________
What are your areas of concern (please circle all that apply):
Uneven Skin Tone
Wrinkles
Crow’s Feet
Acne Scarring
Dry Skin
Eczema
Dehydrated Skin
Psoriasis
Cellulite
Tight Shoulders
Chronic Pain Sore Muscles
Pain Level: High Medium Low
Dark Circles
Dull Skin
Acne
Skin Elasticity
Sun Damage
Stressed Skin
Sagging Skin
Excess Hair
Tight Neck
Injury
Surgery Recovery
Stress
Stress Level: High Medium Low
MEDICAL HISTORY
Allergies:____________________________________________________________________________
Major Illnesses:_______________________________________________________________________
Current Medications:___________________________________________________________________
Sensitivities to heat, cold, smell, etc:_______________________________________________________
Please circle all current or past conditions that apply:
High/Low Blood Pressure
Heart Condition/Disease
Lymph Edema
Varicose Veins/Bruising
Hemophilia/Clotting Disorder
Gas/ Bloating/IBS/Constipation
Broken Bones
Arthritis
Cancer type__________________
Epilepsy
Immune Disorders______________ Scoliosis
Asthma/Medication
Sinus Problems
Claustrophobia
Diabetes Type I or II
HIV/AIDS
Pregnant/Nursingg
Numbness/Tingling
Fibromyalgia
Rosacea
Osteoporosis
Keloid Scarring
Migraines
Metal Rods/Plates/Screws
Pacemaker
Hearing Aid/Contact Lenses
Hepatitis A/B/C
Sinus Problems
Edema
Anxiety/Depression
Thyroid Condition
Vitiligo/Dermatitis
Cold Sores/Herpes/Shingles
Staph Infection
Eczema/Psoriasis/Skin Rash
Sprains/Strains
Sleeping/Eating Disorders
Spasms/Cramps
Headaches/Migraines
Lupus
Fatigue/Dizziness/Vertigo
Other conditions please explain: ____________________________________________________________
(FEMALE ONLY)
Hysterectomy Full/Partial
Irregular Menstruation/PMS Date of Last Menstrual Cycle Date _________
Birth Control Type____________________ PCOS/Medication____________ Endometriosis ___________
NUTRITIONAL INFORMATION
Quality & Quantity of fluid intake__________________________ Water/Coffee/Alcohol/Tea/Soda
List Vitamins/Supplements/Herbal Remedies____________________________________________________
Massage Therapy
Is this your first massage? Yes No
Preferred pressure? Light Medium Deep Very Deep
Massage Goals: Pain Management Relaxation Stress relief Injury Recovery Other:_________________
Skin Care Treatment and Waxing
Is this your first facial? Yes No Date of last facial service:_______________________________________
Have you had/used or currently have/using any of the following?
Botox___________ Fillers___________ Cosmetic Surgery_______ Dermatologist Care___________
Accutane_________ Retin A__________ Laser Treatments________ Chemical/Enzyme Peels________
Dermabrasion______ Hydroquinone _____ Mole/Lesion Removal_____ Electrolysis/Hair Removal______
Topical Antibiotic/Acne Medications ______Bleaching Cremes______
Tanning Beds/Sunless Tanning
Home Skin Care Products
Cleanser brand:__________________ Does it contain Glycolic/Lactic/Salicylic Acid or Enzyme
Moisture: Night crème/brand _____________________ Day Crème/brand_________________________
Toner:___________________ Scrub:____________ Masks:_______________ Eye Cream:____________
Serums: ___________________Sunscreen/brand____________ Makeup Type Brand:________________
Please Initial
______I agree to avoid direct sun after treatment
______I agree to notify therapist with any concerns
______I agree to drink a lot of water
______I do not need a doctor’s release
I understand that aesthetic services offered are not a substitute for medical care and any information provided
by the therapist(s) is for educational purposes only and not diagnostically prescriptive in nature. I understand
that the information herein is to aid the therapist in providing a better service and is completely confidential.
Failure to alert the therapist of any conditions could result in unfavorable outcomes with the treatment.
As with all skin care and massage treatments, there is no guarantee of results. Those prone to cold sores could
have a breakout after treatment. Depending on the treatment(s), I may experience some temporary mild
discomfort such as soreness, bruising, stinging, warm flushing or redness. Adequate water consumption is
critical as well as following a home regiment recommended by your therapist.
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We do require a 24 hour cancellation, unless there is an emergency.
I fully understand and agree to the above policies. I have filled out the history sheet correctly and accurately. I
hereby give my consent to receive spa treatments and release this business as well as the therapist(s) from any
claims (implied or stated) that I have or may have in the future with this of any other treatment, regardless of the
results. I am stating that I understand the treatments I am to receive and possible side effects that may occur.
__________________________________________________
Client Signature
_________________________________________________
Witnessed By:
__________________________
Date