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Personal Information
Please DO NOT fill out the intake form more than 24 hours prior to your scheduled appointment.
If you do, you will have to resubmit the day of. Thank you for your understanding.
Name*
First Last
I pledge to provide only correct and truthful information when completing this screening.*
- I pledge that the information I am providing is correct and accurate
- I cannot consent to the information provided to be truthful
In the last 14 days have you experienced any of the following symptoms?*
- Fever
- Chills
- New or worsening cough
- Vomiting
- Diarrhea
- I have had no symptoms
Have you had direct contact with anyone who has exhibited any of the symptoms in the previous questions, in the last 14 days*
- Yes
- No
Have you had direct contact with anyone who has tested positive for COVID-19 in the last 14 days?*
- Yes
- No
Have you or those who live with you, traveled outside the United States in the last 14 days?*
- Yes
- No
I understand that I and my service provider will be required to wear masks and/or face shields during the duration of the treatment. If I do not have a mask or face covering, one will be provided to me for a PPE cost of $1 at checkout.*
- Yes
Signature*
I understand that because massage therapy and skin care work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner. I also agree to notify Salus Massage Therapy & Skin Care if I develop any COVID-19 related symptoms over the next 14 days. I understand that Salus Massage Therapy & Skin Care will contact me if my practitioner develops symptoms in the next 14 days.
Is this a new service for you OR are you a new client?*
- Yes
- No
Address Verification and Medical History Update Form
Has your address, phone number, email address changed since your last visit? (Select all that apply)*
- New Address
- New Phone Number
- New email address
- No Changes
New Address*
Street Address Address Line 2 City State ZIP Code
New Phone Number*
New Email*
Areas of concern for today's treatment
Has there been any change in your health history since your last treatment? (e.g. new medications, surgeries, injuries, accidents, etc...)*
- Yes
- No
Please list*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Phone Type*
- Home
- Cell
- Office
Date of Birth*
MM
DD
YYYY
Email*
Occupation*
Emergency Contact Name*
Emergency Contact Phone*
Who Referred You?*
- Google
- Yelp
- Facebook
- Road Sign
- Friend or Relative
- Spa Finder, Spa Week or Spa Wish
- Other
Friend or Relative Name*
How would you like to receive your complimentary appointment reminders? Select all that apply*
- Phone Call
- Text
- Email
Would you like to be added to our email list for specials, coupons and newsletters?*
- Yes
- No
Are you a student with a Valid School ID?*
- Yes
- No
Are you a current/retired military member?*
- Yes
- No
Select one:*
- Active Duty
- Veteran
Are you 70 years of age or older?*
- Yes
- No
I understand that it is solely my responsibility to keep the therapist updated on any changes in my physical health, any surgeries, injuries, allergies, accidents or new medications I am taking and I further understand that the company and the therapist shall not be liable for any purpose and for any reason, should I fail to disclose this information.

If I experience any pain or discomfort during this treatment, I will immediately communicate that to the therapist so the treatment can be adjusted.
Date*
Date Format: MM slash DD slash YYYY
Signature*
I agree to all the information and processes above

What are you here for today? (Select all that apply)*
To select multiple services:
For windows: Hold down the control (ctrl) button
For Mac: Hold down the command button
Facial Intake Form
Are you pregnant?*
- Yes
- No
Do you have children?*
- Yes
- No
Have you ever had a facial before?*
- Yes
- No
Do you regularly get facials?*
- Yes
- No
List all current Medications and Topical Medications
Please list any cosmetic surgeries
Do you keloid?*
- Yes
- No
Do you Smoke?*
- Yes
- No
List any Allergies
What Brand do you use for a CLEANSER (if none say NA)*
What Brand do you use for a SCRUB. Is it fine or corse? (if none say NA)*
What Brand do you use for a TONER? (if none say NA)*
What Brand do you use for a MOISTURIZER? (if none say NA)*
What Brand do you use for a SUN BLOCK? (if none say NA)*
What Brand do you use for a SERUMS? (if none say NA)*
What Brand do you use for a MASK? (if none say NA)*
What are your skin care goals? In other words, what do you wish you saw when you looked in a mirror?*
I would prefer communication via...*
- Text
- Phone call
- Email
Consent*
I understand
Please note, a facial may cause the skin to purge resulting in a break out. THIS IS NORMAL and does not mean you are having a reaction to the products. I understand that if I have any questions or concerns, I will reach out or ask my Esthetician.
Signature
Date*
MM
DD
YYYY
Hair Removal Intake Form
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*
- Yes
- No
Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?*
- Yes
- No
Have you used Retin-a, Renova or Accutane in the last 12 months?*
- Yes
- No
Are you using any other skin thinning products and/or drugs?*
- Yes
- No
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
- Yes
- No
Do you use a tanning bed?*
- Yes
- No
Please select any of the following that apply to you:*
- Varicose Veins
- Poor Circulation
- Third Choice
- Recent Scar Tissue Epilepsy
- Hyper Sensitive Skin
- Edema
- Prescribed Medication
- Undiagnosed lumps/bumps
- Moles
- Diabetes
- Skin Diseases
- Warts
- Psoriasis
- Sunburn
- Phlebitis
- Pregnancy
- None of the above
Do you have any open skin lesions or active herpes outbreak (cold sore or genital)?*
- Yes
- No
Have you been waxed/sugared before?*
- Yes
- No
What areas?*
Have you had any of the following procedures? Select all that apply*
- Chemical Peel
- Laser Resurfacing
- Removal of Skin Cancer
- Microdermabrasion
- None of the above
Any Other Major Exfoliation Procedure?*
- Yes
- No
How long ago and on what areas?*
Are you currently taking medications?*
- Yes
- No
Please list all (including over the counter drugs/herbal supplements):*
What skin products do you regularly use on your skin?*
Have you ever been treated for cancer? If yes, when and what types of therapies were used?*
Please list any other illness/condition you are currently being treated for by a medical professional*
Please list any and all allergies you have:*
(Female clients) When is your next menstrual cycle due to begin?
Date Format: MM slash DD slash YYYY

(Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.)
Cancellation Policy/Fees
• Your appointment time was specifically reserved for you, so the courtesy of 24 hour notice for cancellation or rescheduling is appreciated.

• For all new clients, appointments over 90 minutes, couples, and packages; if you fail to give less than 6 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the afternoon before to avoid the fee.

• For all existing clients; if you fail to give less than 1 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the end of the prior business day to avoid the fee.

• Phone call, e-mail, and text message reminders will be provided as a courtesy to you. If you opt out of phone call reminders; please be aware that an automated system sends our e-mails and text messages and we cannot guarantee their reliability; it is your responsibility to remember your scheduled appointments. You can update your reminder method with our front desk staff at any time if your preferences change.

• Bounced checks will incur a $25.00 fee for which a bill will be sent.
Treatment Policies and Etiquette
These policies are in place for your personal protection as well as for the professional dignity of the therapist. You will receive personal instructions on what clothing to remove and how to prepare for the treatment. Please follow those instructions as well as the guidelines that follow:

• Always wait for the therapist to leave the room before getting undressed. Keep a lower undergarment on and cover yourself with the sheet as instructed. You will not be exposed by the therapist during the treatment, and should not attempt to expose yourself. Please do not get off the table at the end of the treatment until the therapist has left the room.

• At no time will any sexual comments, suggestions, activities, or requests be tolerated. If this term is violated, the therapist has the right to end the session, full payment is required, and no further treatments will be scheduled. This is a zero tolerance policy.
Please note that waxing/sugaring does have certain side effects such as skin removal, redness, swelling, tenderness, etc. Please initial each of the following in agreement with the statements.
• I have read the above information and if I have any concerns, I will address these with my skin therapist.*
• I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. *
• I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. *
• I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. *
• I have read and understand the post-treatment home care instructions. *
• I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. *
• In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. *
• I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. *
• I understand the procedure and accept the risks. *
• I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.*
We have the right to refuse services for all waxing if proper hygiene is not followed. For Brazilian and bikini waxes, please use the provided wipe to cleanse area.
Type Client Name*
Signature
I agree to all the information and processes above
Date*
Date Format: MM slash DD slash YYYY
Lashes Intake Form
Do you have any signs of illness? (Examples: Red eyes, stuffy nose, seasonal allergies, etc.)*
- Yes
- No
Please Describe*
New medications, vitamins or herbal supplements since last visit?*
- Yes
- No
Please List*
Were any allergies discovered since your last visit? (Includes adverse reactions experienced)*
- Yes
- No
Please List*
Are you pregnant?*
- Yes
- No
Due Date*
MM
DD
YYYY
Are you on a new diet?*
- Yes
- No
Please Describe*
Do you exercise regularly?*
- Yes
- No
Type/Frequency*
Do you wear daily disposable, extended wear or permanent contact lenses?*
- Yes
- No
If daily disposable, bring eyeglasses?*
- Yes
- No
Have you used any new facial or eye products since your last visit?*
- Yes
- No
Please List*
Have you had your eyelashes tinted in the last 4 weeks?*
- Yes
- No
Have you had any procedures completed on your face or around your eyes within the last 48 hours? (Includes permanent cosmetics, skin-resurfacing, tinting, perming, surgeries, etc.)*
- Yes
- No
Please Describe*
When was the last time you wore cosmetic products on your face or around your eyes? (Include all worn within the last 3 days)*
Type of look desired by client:
Increase in length*
- Subtle
- Noticeable
- Dramatic
Increase in volume*
- Subtle
- Noticeable
- Dramatic
Other design requests:
Signature*
I agree to all the information and processes above
Date*
Date Format: MM slash DD slash YYYY
Massage Intake Form
Have you ever had a massage before?*
- Yes
- No
What brought you in today?*
- Therapy
- Pain Relief
- Injury
- Relaxation
- Other
Please provide details:
Please describe your main concern for today's treatment.*
Please list any surgeries or medical procedures you have had along with the year it took place.*
Are you taking any of the following:*
- Asprin
- Anti-inflamatory
- Pain relieving narcotics
- Cholesterol Medication
- Blood Pressure Medication
- Thyroid Medication
- Cancer Treatment Drugs
- None of the Above
Check any of the following Respiratory or Circulatory issues you have or experienced in the past:*
- Asthma
- COPD
- Hyper tension
- Low Blood Pressure
- Diabetes
- Deep Vein Thrombosis (DVT)
- Heart Condition
- Pacemaker
- None of the Above
Check any of the following Nervous, Skin or other issues you have or have experienced in the past:
- Neuropathy
- Spinal Cord Injury
- Seizure disorders
- Fungal Infection
- Dermatitis/Eczema
- Psoriasis
- Rashes
- Anxiety
- Chronic Fatigue
- HIV/AIDS
- Lupus
- Kidney Disease
- Lyme Disease
- Cancer
- None of the Above
Are you pregnant?*
- Yes
- No
What is your due date?*
MM
DD
YYYY
Cancellation Policy/Fees
Your appointment time was specifically reserved for you, so the courtesy of 24 hour notice for cancellation or rescheduling is appreciated.

For all new clients, appointments over 90 minutes, couples, and packages; if you fail to give less than 6 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the afternoon before to avoid the fee.

For all existing clients; if you fail to give less than 1 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your call by the end of the prior business day to avoid the fee.

Phone call, e-mail, and text message reminders will be provided as a courtesy to you. If you opt out of phone call reminders; please be aware that an automated system sends our e-mails and text messages and we cannot guarantee their reliability; it is your responsibility to remember your scheduled appointments. You can update your reminder method with our front desk staff at any time if your preferences change.

Bounced checks will incur a $25.00 fee for which a bill will be sent.
Treatment Policies and Etiquette
These policies are in place for your personal protection as well as for the professional dignity of the therapist. You will receive personal instructions on what clothing to remove and how to prepare for the treatment. Please follow those instructions as well as the guidelines that follow:

1. Always wait for the therapist to leave the room before getting undressed. Keep a lower undergarment on and cover yourself with the sheet as instructed. You will not be exposed by the therapist during the treatment, and should not attempt to expose yourself. Please do not get off the table at the end of the treatment until the therapist has left the room.

2. At no time will any sexual comments, suggestions, activities, or requests be tolerated. If this term is violated, the therapist has the right to end the session, full payment is required, and no further treatments will be scheduled. This is a zero tolerance policy.
I have read and agree to the above terms:*
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Comments
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