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Please Fill out this Form

Date of Birth
Are you pregnant or lactating?
Yes
No
Do you wear contact lenses/glasses?
Yes
No
Do you have any heart problem/conditions/disease?
Yes
No
Do you currently have high/low pressure?
Yes
No
Do you currently have any open wounds?
Yes
No
Do you currently or regularly use Oral or Topical medications (Accutane, Retin-A, Renova, Differin, Tazorac, Benzoyl Peroxide, or Other)?
Yes
No
Do you have an autoimmune disorder or connective tissue disease?
Yes
No
Do you receive Botox, Filler or Other?
Yes
No
Do you smoke or vape?
Yes
No
Do you take any medication that can cause photosensitivity/light sensitivity?
Yes
No

By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform my esthetician of any changes to the information listed o all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatments unsuitable. I will inform my esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my esthetician and Body Wellness Massage LLC for any  injury or damages incurred due to my  misrepresentation of my health history .

© 2025 Body Wellness Massage. 

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