General Health, Body and Skin Consultation
Thank you for taking the time to answer the following questions. All have a bearing on both your internal and external health and well being, and will assist us when treating you for both body and skin issues.
Birth Date (American style)
Date Picker Icon
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
E-mail Address (if you provide your email, you will receive appointment reminders, a log on for online booking capability, and will be added to the e-news list for special promotions and information)
How did you hear about us?
Walk by / Drive by /Live in Area
Internet Search - led to website
Google Search - led to phone listing
Given a voucher
How would you rate your general health?
Do you have any medical conditions?
Are you currently pregnant?
Please describe all conditions including recent operations, broken bones, contagious skin condition, open sores, easy brusing, nerve pain/disorder, sprain/strain, fever, swollen glands, cancer treatment, heart condition, high or low BP , varicose veins, allergies, diabetes, etc.
Are you currently taking any medications?
Please list all medications
Do you have any allergies or skincare ingredient sensitivities?
Please list here: __________________________
**If you are attending today for a Massage or other treatment only and do not intend to have a skin treatment in the future, please feel free to skip this section**
Are you currently using any skin care products?
Are you interested in learning more about skin care products that would be suitable for your skin concerns?
Questions for all Clients Continued:
How are your stress levels?
Do you regularly do any of the following?
Eat Highly Processed Foods
Drink Alcoholic Beverages
Drink Caffeinated Beverages
How would you rate your 'gut health' (ie digestion)?
1 is Worst, 5 is Best
What, if any, physical activity do you do ie sport?
If you will be using a health fund to claim for remedial massage, please note which fund below:
Please describe below which areas of the body are causing you the most discomfort:
If you believe your discomfort is due to a particular injury, incident or overuse (ie work) please note here:
Please note below if there is any part of the area you prefer not to have treated:
Is there any other information you would like your therapist to know?
Client agreement and waiver: I hereby consent to receiving services from Botanique Skin & Spa. To my knowledge, I have no medical conditions or allergy which would preclude me from having the selected procedures performed. I agree not to hold Botanique Skin & Spa responsible for any and all medical complications that may arise. I have been advised to discontinue use and consult a physician if any reaction occurs. I agree not to hold Botanique Skin & Spa responsible for any and all damage or loss of personal items. I, the undersigned agree to and understand the following:• I have understood all of the instructions and procedure details given to me prior to the session.• I understand that I am responsible for all jewelry, clothing, accessories I wear before and after my session.• While allergic reaction is rare, I assume responsibility for any kind of allergic reaction I may have and will seek immediate medical attention. Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals, and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis I must provide a physician’s written consent prior to services. Draping will be used during the massage session unless otherwise agreed to by both client and therapist. If uncomfortable for any reason the client or therapist may ask to end the massage session, and the session will be ended. All services are purely therapeutic and non-sexual. I understand that massage, body treatments, facials, peels, dermabrasion, light therapy, cosmetic tattooing and all other treatments have a risk of skin irritation, rash, burning sensation, etc. The use of organic products does not guarantee that a reaction won’t occur. All facials run a risk of allergic reactions. I understand that any appointment cancellations with less than 24 hours notice are subject to a cancellation fee equal to 50% of the cost of the scheduled service. I have carefully read and understand all of the above and I have answered all questions fully and accurately. Therapist's Notes:
Thank you for completing the form.
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