Client Lookup

Please locate your account:

First Name

Last Name

Profile Set Up

First Name *

Last Name *

Phone *

Email *

Birthday *

How did you hear about us? *

Address *

City *

State / Province / Region *

Postal Code *

Country *

Emergency Contact

First Name *

Last Name *

Phone *

Massage Intake Form

First massage ever? *

Yes

Date of last spa treatment

Describe

Exercise Frequency:

Exercise Types:

Goals for therapy today:

List and prioritize your current symptoms/issues: (stress, injuries, pain, stiffness, numbness/tingling, swelling, etc.)

Pregnant or recent delivery? *

Yes

High-Risk? (multiples, gestational diabetes, preeclampsia, HBP, etc) *

Yes

Medical History

Are you currently under the care of a specialist? *

Yes

If so, please specify

List medications/vitamins/supplements taken regularly

Do you have any of the following conditions/practices?

Cold/Flu

Eczema/Psoriasis

Edema

Varicose veins

Arthritis/Osteoporosis

Numbness/Tingling

Fibromyalgia

Headache/Migraine

Epilepsy/Seizures

Vertigo/ Dizziness

Scoliosis

Endocrine/Thyroid

Inflammation

Diabetes

Cancer

Kidney disease

Pacemaker

Stroke/Heart Condition

High/Low Blood Pressure

Recent surgery

Fractures/Broken Bones

Injuries

Hernia

Hearing aids

Handicap needs

Skin Cuts/Sores/Burns/Bruises/Rash/Infection

Neurological Disorder

Allergic to:

Algae/Seaweed

Sulfur

Nuts/Seeds

Scents/Smells

Other

Massage and bodywork therapy practices are designed to promote and maintain the health and well-being of the client. These therapies do not include the diagnosis of illness, disease, impairment or disability. If I experience any reactions, pain or discomfort during this session, I will immediately inform the therapist so that the products, pressure and/or manipulations may be adjusted to my level of comfort. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all my known medical conditions and will keep the therapist updated as to any changes in my medical condition.

By signing below, I acknowledge that I have read the above information and give my consent to be treated. This consent form is valid for future treatment, but I will alert the staff is there are any future changes to my medical history. Thank you for completing this questionnaire; by doing so, your therapist can give you the most personalized and effective treatment possible. Your privacy, including the information on this form is strictly confidential, and will not be shared without your permission.

* By signing, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By signing here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

January 17, 2021

Skin Care Intake Form

What type of skin do you feel you have?

Dry

Normal

Oily

Combination

What are your top 3 skincare concerns?

Do you follow a home skin care regimen? *

Yes

Describe (indicate cleansers, toners, serums, moisturizers, masks, etc.)

Any

Rx topicals (Accutane, Retin-A, etc) or

OTC topicals (benzoyl peroxide, glycolic acid, etc)?

Any recent procedures (surgery, plastic surgery, injections, chemical peels, laser hair removal, etc.)? *

Yes

If yes, type/date (if within the past year)

Do you have any of the following conditions/practices?

Sensitive Skin

Pregnant

Smoking

Tanning

Skin infection

Hormonal

Heart Condition

Skin Cancer

Vertigo

Pacemaker

Sun Sensitivity

Easy Bruising

Lymph Nodes Removed

Herpes (cold sores)

Poor Healing

Keloids/Excessive Scarring

Eczema

Psoriasis

Diabetes

Neurological Disorder

Thyroid Disorders

Allergic to:

Algae/seaweed

Nuts/seeds

Sulfur/wine

Citrus

Collagen

Other:

HydraFacial, Microdermabrasion and Peels: Not for sensitive or rosacea-prone skin, or for women that are pregnant. I understand these treatments are resurfacing procedures that exfoliate the skin, the potential risks, and that results are not guaranteed. Most will see results immediately after treatment and feel smoother and more hydrated skin for one to four weeks with appropriate home care to maintain treatment results. I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for a minimum of 2 weeks pre- and post-treatment.

All treatments: I agree that any questions I have regarding skin care treatments have been explained to my satisfaction, and that with any treatment certain risks are involved and that any complications from known or unknown causes could occur, and that possible side effects can include, but are not limited to: mild to moderate irritation, tightness, redness, tenderness, blemishes, or allergic reactions. Most side effects are temporary and will dissipate within 1-7 days. I will call to inform my esthetician of any complications or concerns I may have as soon as they occur. I understand that it is recommended prior to having a facial to NOT have used Retin-A for 72 hours, Accutane in 6 months, or have waxed 24 hours prior to receiving treatment; waxing to NOT have used Retin-A for 2 weeks or Accutane in 6 months. Due to skin being more susceptible after treatment, avoid sun exposure and use 30+ SPF sunscreen every day.

By signing below, I acknowledge that I have read the above information and give my consent to be treated. This consent form is valid for future treatment, but I will alert the staff is there are any future changes to my medical history. Thank you for completing this questionnaire; by doing so, your esthetician can give you the most personalized and effective treatment possible. Your privacy, including the information on this form is strictly confidential, and will not be shared without your permission.

HydraFacial Optional:

Since the HydraFacial has cameras for before/after images, I give permission for my images to be used by Kur Wellness Studios for marketing and education purposes. Although most often the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may, or may not be, identified by the images.