Within the last year, have you been under a dermatologist or other physicians care?
Within the last nine months, have you been undergone any surgeries?
Have you had any health problems in the past or present?
Do you wear contact lenses?
Rate your level of stress on a scale of 1-4 (1=lowest; 4=highest)
Please list any medications, supplements, vitamins, diuretics, slimming tablets, etc., that you take regularly:
Please select your skin type
Do you ever experience skin breakouts?
Do you ever experience oily shine during the day?
Do you ever experience a burning, itching sensation on your skin?
Do you ever experience a reaction to any of the following?
What is your pain threshold? (1 = no pain, 10 = lots of pain)
What are your skin care goals?
For Females Only
Are you pregnant or trying to get pregnant?
Do you have any special skin problems pertaining to your face or body?
What kind of products are you currently using?
Do you use Accutane, Retin A, Renova, Adapalene, or other prescription skin products?
Have you ever had chemical peels, microdermabrasion, or resurfacing treatments?
How much water do you consume daily?
Is there anything else about your current or previous health history you think would be useful for your esthetician to be aware of to make this a better experience?
Do you experience these conditions on your skin?
What SPF sunscreen do you use on your face?
What SPF sunscreen do you use on your body?
Do you sunbathe or use tanning beds?
Do you burn easily in moderate sunlight?
Clients under the age of 17 must have a parent or legal guardian present to provide a signature for authorization of this facial session. It is my choice to receive spa treatments. I realize that the treatment is being given for the well being of my body and mind. I agree to communicate with my service provider any time I feel as though my well-being is being compromised. I understand that the service providers do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, or pharmaceuticals. I acknowledge that spa services are not a substitute for medical examination or diagnosis, and that it is recom mended that I see a primary Health Care provider for that service. I have stated all medical conditions that I am aware of, and will update the service provider of any changes in my health status. I understand that all employees of Rosehaven Spa are licensed profession, and that by law they have the right to refuse service on any client at any time, if they feel as though their well-being is compromised. I understand and voluntarily accept the risks associated with the facial and/or any other services, including but not limited to: Massage, Facials, Sauna, ZIFiT, ECT. or the use of any of the location’s facilities. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the use of Full Spectrum Infrared Sauna, or any other program, event or activity. I agree Rosehaven Spa will not be liable for death or any injury, including, without limitation, personal, bodily or mental injury, economic loss or damage to me resulting from negligence, other acts in Rosehaven Spa, anyone acting on Rosehaven Spa’s behalf, or anyone using the services of the facilities of Rosehaven Spa, to the fullest extent permitted by law. This agreement together with Rosehaven Spa's wellness plan rules and regulations, constitute the entire agreement between you and us and cannot be amended, except in writing by both parties. Myself and/or any of my heirs, executors, representatives, or assignees hereby release Rosehaven Spa from all claims or liabilities for death, personal injury or property loss or damages of any kind sustained while on the premises, during the use of the full spectrum Infrared Sauna and/or from any advice or services provided by an employee, independent contractor or any representative of Rosehaven Spa. I agree that this application and waiver is in effect for all massages, facials and/or Full Spectrum Infrared Sessions or any other services, and will not expire unless specifically requested by either party. I understand that Rosehaven Spa is a tranquil and professional environment and that any inappropriate behavior may result in termination of my services and full payment is expected. By signing this form, I agree to the above terms and release Rosehaven Spa and its employees from any liability.
For Parents/Guardians of Participant Of Minor Age (Under age 18 at time of registrations): This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree to his/er release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabiity incidents to my minor child’s involvement or participation in these programs as provided above, to the fullest extent permitted by law.
Parent/Guardian if Minor