Intake Form Today's Date * MM DD YYYY Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone * (###) ### #### How did you hear about us? List any medications, supplements, or herbal remedies you currently take * List allergies or sensitivities: * List any injuries or surgeries: * Have you ever received professional skin care treatments? * Select One Facial Massage Both None What are your specific concerns at this time regarding your skin? * What is your stress level right now? * Low Average Somewhat stressed Very stressed What do you consider your skin type? * Normal Oily Acne Dry Aging Combination Sensitive Rosacea Other What is your daily skin care regimen? * Please check all that apply. * Pregnant Postpartum Neck Pain Back Pain Headaches High Blood Pressure Bruise Easily Diabetes Seizures Knee / Leg Pain Jaw Pain / Clenching / Grinding Metal Implants Fibromyalgia Used Retin-A within the past 10 days None What is your goal for this session? * By SUBMITTING THIS FORM, you agree to the following: * 1) I give my permission to receive facials or waxing services. 2) I understand that skin treatment is not a substitute for traditional medical treatment or medications. 3) I understand that the therapist or esthetician does not diagnose illnesses or injuries, or prescribe medications. 4) I have clearance from my physician to receive facials and massage therapy. 5) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to: • Superficial bruising or redness • Short-term muscle soreness • Exacerbation of undiscovered injury I, therefore, release Lindy's Skin Studio and the individual therapist or esthetician from all liability concerning these injuries that may occur during the treatment session. 6) I understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition. 7) I understand that it is my responsibility to inform my therapist or esthetician of any discomfort I may feel during the session so he/she may adjust accordingly. 8) I understand that I or the therapist may terminate the session at any time. 9) I have been given a chance to ask questions about the session and my questions have been answered. I agree Cancellation Policy * Because Lindy's Skin Studio is by appointment only, your appointment is time reserved exclusively for you and we request that you please review our cancellation policy. I agree I will be in contact to schedule. Thank you!! Cancellation Policy