Client Intake Form New Client Intake Form Step 1 of 6 - Personal Information 0% Name First Last PhoneDate Date of Birth OccupationCity / StateHow Did you hear about us? LifestyleRate your level of stress on a scale of 1-10Are you on any medications?YesNoIf you are on any medications, please list...Have you had recent cosmetic surgery or accidents?YesNoIf you have had recent surgery, please explain...Are you less than 6 weeks postnatal, pregnant or planning a pregnancy?YesNoHave you had this kind of treatment before? How often?YesNoWhat do you wish to achieve from today’s visit? Massage / Body TreatmentsIs there a specific area you would like worked on?Have you suffered from any sport injuries, sprains, or fractures?YesNoIf you have suffered from any injuries, please explain...Have you suffered joint, neck, spinal, or back problems in the past 2 years?YesNoDo you have any of the following? Arthritis Claustrophobia Heart Condition Pacemaker Iodine (seaweed) Allergy Metal Pins/ Plates Rheumatism High / Low Blood Pressure Allergies/Other If you have selected any of the above boxes, please explain... Facials and WaxingDo you experience any of the following? Dryness Sensitivity Broken Capillaries Oiliness Fine Line / Wrinkles Age Spots Puffy Eyes Sun Damage Dark Circles Acne Breakouts Burns Rosacea Decreased Elasticity Product Sensitivity Dehydration Scarring Muscle Pain / Cramps Contact Lenses Herpes Allergies If you selected any above, please feel free to ecplain...Have you ever had laser treatments?YesNoAre you currently using Accutane/AHA’s, Glycolics, Retin A or any other skin thinners? In the past 72 hours?YesNoAre you exposed to the sun for a significant amount of time on a daily basis?YesNoDo you use a tanning bed?YesNoIf you do use a tanning bed, how often?If you do use a tanning bed, how often? Ear CandlingDo you wear a hearing aid?YesNoHave you ever had an ear cleansing?YesNoPrimary goal/concern for Ear Candling?Check symptoms you currently have or have had in the past: Ear Aches Swimmer's Ear Ear Discharge Headaches Sore Throat Loss of Hearing Ringing Migraine Excessive Ear Wax Dizziness Sinus Problems Allergies *Please note, there are no refunds nor discounts after service is completed. If for any reason you are not 100% satisfied with your treatment, notify your service provider during your session. I certify that the above information is correct to the best of my knowledge. The undersigned, understands, acknowledges and agrees that (I) I am aware that the facilities and services offered by A Touch of Las Vegas Day Spa LLC., involves risks, included but not limited to risks of bodily injury. (II) I have provided above all the relevant information regarding my medical history and current health status. (III) I am making use of A Touch of Las Vegas Day Spa LLS., at my own free will and (IV) I assume all risks associated therewith. One behalf of myself and my heirs I hereby release and discharge the entity that operates A Touch of Las Vegas Day Spa LLC., (the “owner”) and all of the affiliates, employees, directors, officers, agents, landlords, representatives, successors and assigns of the Owner from any and all claims or causes of actions arising out of or relating to my use of the facilities and services of that entity, including but not limited to, those resulting in bodily injury or theft, or loss of, or damage to. Property of mine unless due to gross negligence or willful misconduct of the Owner of its employees. I Agree to Liability Release, Acknowledgement and Waiver I agee with Liability Release By checking this box you agree with the Liability Release, Acknowledgement and WaiverDate This iframe contains the logic required to handle AJAX powered Gravity Forms.