Facial Intake Form – soothespagrandlodge.com

Name*

First Last

Email*

Phone*

Date of Birth*

Are you wearing contacts?*

Are you pregnant?

How many weeks?

Medical Release for Prenatal Spa Treatments

Soothe Spa provides a variety of spa services, treatments, therapies and procedures. Certain Spa Treatments are not recommended for pregnant women during the first trimester of pregnancy, including massage therapy, body wraps, hot stone massage, reflexology and aromatherapy which are considered contraindicated services ("Treatments" used individually or collectively). If you are pregnant, it is suggested that you discuss receiving these services with your prenatal healthcare provider prior to receiving any such treatments.

I verify that I have discussed with my prenatal healthcare provider/physician any health concerns that I had about my participation in any Spa Treatments, including without limitation any contraindicated services listed above, and I understand and freely accept the potential risks of such Spa Treatments. I also understand that I am free to withdraw my consent and to discontinue participation in any Treatments at any time. Having read, discussed, and understood the above information, I further verify that I have obtained my prenatal healthcare provider's release and disclosed all high risk conditions of pregnancy. I do forever release the Spa, its therapists, practitioners, employees, agents, and each of their insurers, from all liability of any occur to of any nature whatsoever, whether past, present, or future for any injury or damage which may occur to myself or my family as a result of my participation in any Spa Treatments. I also agree to hold harmless and defend the Spa, its therapists, practitioners, employees and agents from all actions, claims, or other legal or administrative action that arises or may arise directly or indirectly out of my and my child's participation in any Spa Treatments.

Consent

I have read and accept the Prenatal Medical Release conditions

How did you hear about us?

For Facial Service

Have you had any of the following symptoms within the last 72 hours?

Fever/Chills
Shortness of Breath/Difficulty Breathing
Congestion or Runny Nose
Dry Cough
Sore Throat
Loss of Taste or Smell
Fatigue
Nausea
Rash: Open Wounds; Warts (Hands/Feet)

I will keep my face covered in indoor areas open to the general public whenever six feet of separation cannot be maintained.*

I agree

Have you had a facial before?*

Yes
No

How long ago?

How would you describe your skin?*

Oily
Dry
Combination

Have you had any facial surgery?*

Yes
No

If so, when and what type?

Are you on any skin medication?*

Yes
No

What type?

Do you have any metal implants in your face?*

Yes
No

Where?

In the last month have you had any:*

Botox
Fillers
Microdermabrasion
Chemical Peels
None of the above

I do not have any open skin lesions or active herpes outbreaks (cold sores or genital).*

I agree

Are you taking any medications or pain killers at this time?*

Yes
No

What type?

Have you had any reactions to skin care products?

Yes
No

Please list:

Are you sunburned or windburned?*

Yes
No

What does your current skin care regimen consist of?

Cleanser
Exfoliant
Mask
Toner
Eye Cream
Moisturizer
SPF

Why are you getting a facial and what would you like to achieve?*

I am least 18 years of age.*

Yes
No

All Soothe Spa massage therapists will work with-in the scope of this minor massage policy:
All minors age 14 and under:
• Parent must sign the minor’s health history form
• Parent is required to be present in treatment room during the massage service
• Minor must wear underwear during the massage service
• Massage therapist must be same sex as minor

All minors age 15 to 17:
• Parent must sign the minor’s health history form
• Parent is not required to be present in treatment room during the massage service
• Minor must wear underwear during massage service
• Massage therapist must be same sex as minor

Minor Massage Policy*

I have read and accept the Minor Massage Policy

Facial Upgrades

Our staff is dedicated to providing a luxuriously tailored treatment for you. Please see our specialty upgrades. Please note these upgrades do not add additional time to your treatment.

Please select any specialty upgrades you would like to add to your service:

CBC Facial Massage - $15
Collagen Eye Treatment - $15
Collagen Lip Treatment - $15
Kaplan Lip Treatment - $15
Sinus Soother - $15

Facial Services Consent

I certify that the above information is complete and correct. I will keep the therapist informed of any changes as they occur. I will be responsible For making payments on any appointment which is not cancelled 24 hours in advance. I understand that Breckenridqe Grand Vacations, Soothe Spa, and any therapist working at this business will not be liable For any injuries or loss sustained to myself or property at this location, and that the procedures I am receiving are not intended to be a substitute for professional medical treatment for any condition.

Consent*

I agree to the policy

Facial Service Payment

I authorize Soothe Spa to charge the amount of my service to the credit card on file.*

Yes
No

I understand that if I do not provide the appropriate cancellation window which is 24 hours in advance of my service my card will be charged for the full cost of service.*

I agree to the policy

I would like to include a gratuity for my service provider:

25%
20%
18%
Other

Tip Amout