Everythingzenmassage.com

Welcome to Everything Zen. It is my commitment to provide you with holistic health services that enhance your body’s natural ability to heal. All therapies are customized to your unique needs. Together, we will create a plan based on your lifestyle and personal goals to optimize your health and wellness. Thank you for the opportunity to share in your well-being and re-laxation.
Financial Policies for Everything Zen:

Dear friends and valued clients,
Both of our time is valuable, and your appointment time is held especially for you. We
understand that life occasionally happens, and there may be a need to reschedule. We
appreciate more than 24 hours notice, but in the event that less than 24 hours notice is given,
a $50 fee will be charged to you, and payable upon your next visit. As of July 1st, 2011, tax
will be charged on facial and waxing services. (All other services are non-taxable.) All gift
certificates are FINAL, and can be used toward any product or service at Everything Zen. Due
to Department of Health regulations, all opened retail purchases are NON-REFUNDABLE.
Thank you for your understanding, and by signing below, you agree to our financial policies.
Signature: ________________________________________________________________
Today’s Date: _____________________________________
ORGANIC SKIN CARE ~ THERAPEUTIC MASSAGE ~ REFLEXOLOGY
495 Gold Star Highway, Suite 320, Groton, CT 06340 860-861-8978
www.everythingzenmassage.com
FACIAL INTAKE FORM
Name______________________________________ Phone ( )_____________ Cell ( )_________________ Address ___________________________________________________________________________________ City _______________ State ___ Zip __________ E-Mail ___________________________________________ Referred by __________________________________________________ Emergency Contact __________________________ Relationship _________________ Phone ( )______________ 8. Are you presently taking any medications? If so, 2. What is your main concern with your skin? please list: _______________________________ ___________________________________________ ________________________________________ 3. Are you presently under a physician’s care for any current skin condition or other problems? If yes, please explain ____________________________ 11. Do you have any allergies to cosmetics, food or ________________________________________ drugs? If so, please list: _____________________ _________________________________________ 5. Are you taking birth control pills? Yes No If so, what type? __________________________ If so, what and when? ______________________ 6. Are you presently using (or used in the past): ________________________________________ Azelex, Differin, Renova, Retin-A, Tazarac, Glycolic, 13. Do you often experience stress? Yes No or Alpha Hydroxy Acids? If so, when and for how 14. What skin care products do you presently use? long? __________________________________ ________________________________________ 7. Are you now using or have you ever used Accutane? ________________________________________ Please circle if you are affected by or have any of the following: Please explain above problems or list any other significant issues __________________________________________ ______________________________________________________________________________________________ Draping will be used during the session—only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian. I understand that the services offered are not a substitute for medical care and any information provided by the thera-pist is for educational purposes only, and not diagnostically prescriptive in nature. I understand that the information herein is to aid the therapist in giving better service and is completely confidential. I, ________________________________(print name) understand that the facial I receive is provided for the basic purpose of relaxation and natural skin care. If I experience any pain or discomfort during this session, I will immedi-ately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that a facial should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. Signature of Client_________________________________________________ Date__________________________ Signature of Therapist______________________________________________ Date__________________________ ORGANIC SKIN CARE ~ THERAPEUTIC MASSAGE ~ REFLEXOLOGY
495 Gold Star Highway, Suite 320, Groton, CT 06340 860-861-8978
www.everythingzenmassage.com

Source: http://www.everythingzenmassage.com/FacialForm_Policy_EverythingZen.pdf