CONSULTATION FORM

FACIAL CONSULTATION FORM

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FACIAL CONSULTATION FORM

Name*

Email Address

Phone no:

Date:

How did you hear about us? ( referral )

Speed mapping you started with La Ritz Spa and Salon's skin health system.

On your next visit ask for a more in-depth personal consultation from our licensed skin therapists. To begin, we need to know a few things about you. 1.) Is this your first introduction to La Ritz skin analysis? Yes or No

2.) Have you ever used professional grade skin care products before Yes or No pls specify

YOUR SKIN

3.) Have you ever had a facial treatment before ? Yes or No What type and When?

4.)Have you ever had a chemical peels, laser, microdermabrasion?

Yes or No In the last month? Yes or No

5.) Which of the following best describes your skin type?

a) Always burns easily, never tans b) Always burns, tan slightly c) Burns moderately, tans gradually d) Seldom burns, always tans well e) Rarely burns, deep tan f) Never burns, deeply pigmented

6) What areas of concerns do you have your:

SKIN: ( please choose all that applies ) breakouts/acne , broken capillaries, wrinkles/fine lines, blackheads/whiteheads, redness/rudiness, dull/dry skin, excessive oiliness/shine, sun spots/sun damage, uneven skin tone, dehydrated.

EYES and LIPS

Dehydrated, puffiness, Wrinkles (crows feet), Dark circles 7.) Do you have any OTHER special skin problems or concerns pertaining to your face and body? Yes or No

8.) do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/Vitamin A products? Yes or No

Specify. In the last 3 months? Yes or No

9.) Have you used an acne medication? Yes Or No

When and which drug?

10.) Have you experienced Botox, Restylane or Collagen Injections?

Yes or No. Please specify.

FEMALE CLIENT ONLY

11.) Are you taking oral contraceptives? Yes or No specify

12.) Are you pregnant or trying to become pregnant? Yes or No

13.) Any menopause issues? Yes or No specify

14.) Are you undergoing hormone replacement surgery? Yes or No Specify

MALE CLIENT ONLY

15.) What is your current shaving system? wet shave or electric razor .

16.) Do you experience irritation from shaving? Yes or No Ingrown hairs? Yes or No

Please put your signature and date.

I understand have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contradictions and or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care institution from liability and assume full responsibility there of.

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Massage Consultation Form

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MASSAGE CONSULTATION FORM

Name*

Email Address

Date

Emergency Contact

Phone no.

Male / Female

Please describe any experience with massage:

Reason for today's visit:

How did you hear us? (referral?)

Medical History: Please Check All That Apply:

Please choose: High Blood Pressure, diabetes, asthma, epilepsy/seizures, cuts, bruises, fractures, respiratory disorders, low blood pressure, varicose veins, headaches, spinal disorders, psychological disorders, arthritis location, pregnancy, heart diseases, phlebitis, Fibromyalgia, surguries, Gastrointestinal Problem, Muskuloskeletal Disorders, stroke, cancer, gout, stress, TMJ Disfunction, accidents, skin disorders..Please explain any chosen illness.

Would you like light ,medium, or deep pressure during your massage?

Please list any allergies:

Current Medications:

Herbs ( ) Yes () No if yes, list

Are you currently under a physicians care? ( ) Yes ( ) No Why ?

Do we have permission to contact them if the need arises?

Yes or No

Please put your Doctor's name, phone and affix your signature.

I understand that the massage/bodywork I receive is provided for the basic purposes of relaxation and relief of muscular tension. There are certain medical conditions in which receiving a massage may not be appropriate. In those cases a referral from a physician may be required prior to services being provided. Massage/bodywork is not a substitute for medical specialist. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure/strokes may be adjusted. In addition, if I am uncomfortable for any reason. I may ask that the session be stopped immediately. Draping will always be used during sessions. No breast massage will be done without the written consent of the client and the therapist. Any illicit or sexually suggestive remarks or advances made by me ( the client ) or the therapist will result in an immediate termination of the session.

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ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM

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ELECTRO-STIMULATION/CAVITATION SLIMMING CONSULTATION FORM

Name*

Email Address

Date

Emergency Contact:

Male/Female

How did you hear about us?

This treatment is not for those who have any of the following:

Any form of blood sickness, Skin diseases or sickness, Heart disease, Metal inside the body, pregnant, Tumors.

Please affix your signature and date:

I understand,have read,and completed this document truthfully. Iagree that this constitutes full disclosure,and that it supercedes any previous verbal or written disclosures.I understand that withholding information or providing inaccurate information is serious.The treatments I receive here are voluntary and I release my body institution from liability and assume full responsibility thereof.

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WAXING CONSULTATION FORM

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WAXING CONSULTATION FORM

Name*

Email Address

Date

Phone no.

Please answer the question below

Please choose whether you have now or ever had any of the following medical conditions: Diabetes, dermal abrasions, stomach ulcers, high blood pressure, excessive moles, poor circulations, warts, varicose veins, any other skin conditions (please explain below)

Please choose whether you are taking any of the following medications.

Acadian, tetracycline, coition, high blood pressure, thyroid med, rein-A, glycolic acid, alpha hydroxy acid, any other medications (please explain below)

Are you under the care of a Dermatologist?

Please indicate below the date of your most recent?

Tanning (sun), Tanning (bed), Chemical peel, Waxing

Please affix your signature below

Do not expose skin to sun/indoor tanning for at least 48 hours after the waxing service.I understand that i am accepting any reactions from a waxing service.

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CHEMICAL PEEL/MICRODERMABRASION CONSULTATION FORM

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CHEMICAL PEEL/MICRODERMABRASION CONSULTATION FORM

A Skin peel is not a "cure-all" treatment,but for appropriate conditions,it can improve the skin. It is very important that you have a thorough understanding of what a peel can and cannot do for your particular condition. Please initial each statement and sign this form

I,________________________________________________________________give microdermabrasion consent to ___________________________________________

to perform a skin peel/microdermbrasion treatment on my face or body in order to treat the following conditions:__________________________

_____________________________________________________________________________

_______ The peel treatment was explained to me.

_______I understand that the degree of improvement I can expect to see is dependent on many variables,and therefore cannot be guaranteed.

Additionally, I understand that good home care and adherence of ALL

instructions is vial to ensure my best results.

______I understand that this program of treatment, and that I may need several peels in order to achieve my best results.

______ I understand that I can expect to have 1-2 minutes if stinging or burning immediately after the peel has been applied- or no longer with certain peels.

______ I have ceased the use of Hydroquinone/Salicylic/Glycolic acid products, 1 week prior to service.

______ I have not received any chemical hair treatments (permanent wave,straightening,relaxers,coloring, or bleaching) 1 week prior to service.

______ I do not at this time suffer from HIV, Hepatitis,Herpes, simplex

( cold sore ) infections or facial warts. (Note: the appearance of a cold sore on the lips or any other portion of the peeled area must be cared for immediately.The cold sore can spread if not treated promptly.)

______I have informed the esthetician if I suffer from diabetes.

_____I am not currently undergoing chemotherapy,radiation, treatments or using anti-cancer drugs at this time.

_____ I am not pregnant or breastfeeding at this time.

_____I am not sun burned at this time.

_____I do not have permanent make-up ( eyeliner,brow liner,lip-liner)or I have notified the esthetician so that my tattoo will be covered as not to fade or discolor ink.

_____I understand that I MUST use an SPF of at least 30 for the next 2 weeks following each treatment. (Physical sunblock is recommended,

A quratre size amount must be applied every morning.) I will avoid direct sun as much as possible and wear a hat when I am outside.

______ I understand that the use of tanning beds in between treatments will nuliffy the results achieved and worse, can cause sever burns.

______ I have not been taking Accutane for the past year.

______I have not notified the esthetician of any allergies to ASPIRIN or SHELLFISH.

PATIENT CONSENT:

The esthetician has explained to me the possible complications of the proposed chemical peel and I have sufficient opportunity to ask questions.I understand that the chemical peel treatments cause a burning sensation that will last several minutes. Multiple peels may be necessary to achieve the desired results,especially with light chemical peels,depending on my skin type and the nature of my skin problem. I have realistic expectations as to degree of improvement a chemical peel may provide.

After receiving and understanding in full the information above, I freely give my consent to undergo the chemical.I understand that this procedure is cosmetic and that the payment is my responsibility. My questions have been answered by the staff to my satisfaction.I release

the esthetician of liability and I accept the risks and complications of procedure.

_____________________________

Patient/Client Signature

______________________________

Witness Signature

_____________________________

Date

By signing below,I am standing that there are no changesfrom when I signed this consent.I have not started any new medications or been in the tanning beds,etc. I consent to the chemical procedure and agree to all the information that i has signed previously.

Treatment 1

___________________________________________________________________

Signature/Date

___________________________________________________________________

Witness/Date

FOOT DETOX CONSULATATION FORM

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FOOT DETOX CONSULTATION FORM

Name*

Date

Address

Email address

Phone no.

Do you experience fatigue or low energy levels especially around 3 pm in the afternoon?

Do you experience brain fog, lack of concentration and or poor memory?

Do you eat fatty foods,fast foods, and pre -prepared foods, or fried foods on a regular basis?

Do you drink sodas and coffee during the day to get yourself going?

Do you smoke cigarette?

Do crave or eat sugary snacks, candies, or desserts?

Do you have less than 2 bowels movement per day?

Do you feel sleepy after meals,bloated, and or gassy?

Do you experience heartburn or indigestion after eating?

Are you over weight or do you rarely exercise?

Do you experience reoccuring yeast or fungal infections?

Do you experience frequent headaches or migraines?

Do you have arthritis aches,and pain stiffness?

Do you take prescriptive medicines on a regular basis?

Do you have prescriptive sedatives, or stimulants?

Do you live with or near polluted air,water, or other environmental pollution?

Do you use fluoridated toothpaste or drink flouridated/chlorinated water?

Do you experience depression or mood swings, ( mental highs or lows?

Do you have bad breathe or excessive body odor?

Do you have food allergies or bad skin?

Are you showing signs of premature aging?

Have you ever used an internal cleansing product or followed a complete internal cleansing program?

If YES

**If you answered "yes" to 4 or more of the above questions or answered "no" to questions 22, then you are a good candidate for foot detox and would greatly benefit from a # month detoxification treatment schedule**

If any of these conditions exists then FOOT DETOX is not for you:

Use a pacemaker or other electronic medical equipment, take medication for hypertension, have had an organ transplant, take specific medicine for a psychological condition, are you pregnant or nursing, persons with Epilepsy, persons with open wounds in their feet, person currently undergoing any form of radiation or chemotherapy, people who are hemophiliac and those taking blood thinners, children under 8 yrs old.

Please affix your signature and date:

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