Pink Feathers

New Client Intake Form

What is the reason for your visit today?
Is this your first massage ever?

CONFIDENTIAL CLIENT INFORMATION AND HEALTH HISTORY

Gender
Please select if you are, affected by or have any of the following conditions:
Have you ever done or any Ultrasound Cavitation or treatment?
Do I need to take extra precaution?
Have you ever had chemotherapy?
Have you had a chemical peel or any type of procedure with a medical device?
Have you recently had any type of aser resurfacing
Do you have regular collagen, Botox or other dermal filler injections?
Are you allergic or sensitive to massage oils, creams, lotion, essential oils?
Is there any other diseases or disorders not listed above that we should be aware of?

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.

Cancellations must be done, 24 hours prior to the reserved appointment time, to avoid fee charges. By signing this document, I (you) understand that any illicit or sexual suggestive remarks advances will result in immediate termination of the session. I (you) affirm that all information provided above is correct to the best of my knowledge.

Thanks for submitting!