Intake Please enable JavaScript in your browser to complete this form.Name *Phone Number *Email *AddressState *Zip Code *Would you like to receive email appointment notices and monthly news letters?YesNoEmergency Contact *Emergency Contact Phone *Allergies/SensitivitiesLatexPeanutTree nutsShell fishIodineGlutenDairyEggFishSoyCoconutOtherOtherHave you ever had an adverse reaction to any cosmetic procedure or products?Do you have any of the following:Plates/PinsJoint replacementPace makerContact lensesClaustrophobiaBlood sugar issuesBlood pressure problemsHave you had any surgeries?Are you taking hormone therapies or birth control?Are you pregnant, trying to become pregnant, or nursing?Are you on blood thinners/aspirin therapy?Are you prone to cold sores?Are you on any other medication that I should be aware of?Do you have asthma or other breathing problems?Do you have any stress or anxiety problems?Do you have any problems with or is your doctor concerned with raised body temperature?In a day how much do you consume: caffeine, alcohol, smoke/vapeIs there anything else I should know about you to best service you?Signature *FirstLastI understand that by not fully disclosing my health and habits I may be more prone to adverse reactions from services. To the best of my knowledge the above information is correct.Submit
