310 915 0900 contact@escapedayespala.com

Client Intake Form

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CONFIDENTIAL CLIENT INFORMATION AND HEALTH HISTORY
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Please switch if you are affected by or have any of the following conditions:
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I understand that massage therapists/esthetician do not diagnose disease, prescribe medication or manipulate bones. I further understand that massage therapist/esthetician is not a substitute for medical attention or examination. Because massage therapy should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health and understand that shall be no liability on the practitioner's part should I forgot to do so.

Waxing: may cause Bruises, scabs, scarring, redness, hyper pigmentation or pimples. The use of a new product increases the possibility of a reaction, so before the esthetician starts waxing inform her/him if you ever had a product reaction.

Cavitation Ultrasonic/RF: I was told the possible side effects of the treatment include: local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister, and burn), fragile skin and bruising. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.

I understand that not everyone is a candidate for this treatment and results may vary. I confirm that I have read and understand the above information and will undergo the treatment out of my own free will. I believe I have adequate knowledge upon which to base an informed consent.

I understand that all payments are due at time of service.

I understand that I am responsible for all charges. Money for prepaid packages is non-refundable, however, credit for services yet to be delivered may be applied to receiving any other services or products offered at ESCAPE DAY SPA.

Cancellation of appointments must be done 24 hours prior to the appointment to avoid fee charges. It is also understood that any illicit or sexual suggestive remarks advances made by me will result in immediate termination of the session. I affirm that all information provided above is correct to the best of my knowledge.

BUSINESS HOURS

Mon - Fri: 10am to 9pm
Sat - Sun: 10am to 7pm

E-MAIL

TELEPHONE

310-915-0900

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