Name

First Name

Last Name

Preferred Name:

Date of Birth

Birthday

YYYY

Preferred Pronouns (EX: She/Her)

Phone

How did you hear about us?

Occupation

Are you currently under any medical care or have an injury we need to be aware of? Please describe

Please list any allergies:

Have you ever had complications during a massage, body treatment, facial, waxing or nail service?

Please indicate if you have any medical conditions or communicable diseases:

Do you have foot fungus?

Yes

Do you have athlete’s foot?

Yes

Are you currently under the care of a podiatrist?

Yes

If you are pregnant, how far along?

Have you ever had a professional massage, facial or body scrub/wrap?

Yes

What type of massage pressure do you prefer?

Are there any areas of your body you would like us to avoid?

To benefit the most from your treatment, please list areas or concerns you would like your spa provider to give attention to:

What are your skin care concerns/sensitivities? Please list any doctor prescribed medications for skin. What products are you currently using?

If you are receiving a facial, please provide the most information you can.

If I am receiving an Advanced Facial or Skin Peel I understand:

I understand that results achieved may vary from person to person.

I understand that the number of treatments also vary from person to person.

I certify that I have not used Retin-A or Accutane in the last 6 months.

I understand proper home care after my service is required for optimal results and outcome.

I have consulted with the esthetician and all of my questions have been answered to my satisfaction. I understand the treatment and it is solely my decision to have this treatment

As A Guest Of Blooming Moon Spa:

I do not have any following symptoms: Fever / chills, cough, shortness of breath / difficulty breathing, fatigue, muscle / body aches, headache, new loss of taste / smell, sore throat, congestion / runny nose, nausea / vomiting, or diarrhea.

Thank you for completing our intake!

The information above is true and correct to the best of my knowledge. I understand that the practitioners do not diagnose illness, disease or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals or perform spinal manipulations. I acknowledge that my service is not a substitute for medical examination and diagnosis, and it is recommended that I consult with my primary health care provider for that service. I understand that under Oregon law if there is any fungus or disease that the practitioner perceives as a potential risk, that the service may be discontinued at any time. I also agree that I am responsible for any damages or injuries from my failure to provide accurate information about my health status. Spa Etiquette Guide: Please silence phones and phone use is prohibited. As a courtesy to the next guest, if you arrive late your treatment will end as previously scheduled. As a courtesy to other guests please speak softly and please no loud, unattended children. Blooming Moon is not responsible for lost or damaged personal property while receiving services.

Thank you for completing Blooming Moon Spa’s intake form. If you have any question please do no hesitate to ask your spa provider.

Blooming Moon Spa Intake Form

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