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La Ritz Consultation Forms

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FACIAL CONSULTATION FORM


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
3.) Have you ever had a facial treatment before ? Yes or No What type and When?
Yes or No In the last month? Yes or No
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
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.
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
Specify. In the last 3 months? Yes or No
When and which drug?
Yes or No. Please specify.
11.) Are you taking oral contraceptives? Yes or No specify
15.) What is your current shaving system? wet shave or electric razor .
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 


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.
Herbs ( ) Yes () No if yes, list
Yes or No
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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WAXING CONSULTATION FORM


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)
Acadian, tetracycline, coition, high blood pressure, thyroid med, rein-A, glycolic acid, alpha hydroxy acid, any other medications (please explain below)
Tanning (sun), Tanning (bed), Chemical peel, Waxing
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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FOOT DETOX CONSULTATION FORM


**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**
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.
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Microblading consultation form


Latex Lanolin Vaseline Medication Metals Hair Dyes Foods Lidocaine Paints Crayons Glycerin
If yes, you must contact your physician for a preventative prescription capsule to prevent a cold sore.
Retin-A in last 2 wks Anemia Sensitivity to cosmetics Prolonged bleeding Diabetes Trichotillomania Epilepsy Artificial Heart Valve Low Blood pressure High Blood Pressure Hemophilia HIV Alopecia Liver Disease Fainting spells or dizziness Circulatory Problems Hypertrophic scars Cancer Tumors, growths, cysts Botox/filler injections Thyroid disturbances Keloid scars Chemical/laser peel in last 6 wks Healing problems AHA’s in last 2 weeks Hair Loss Hepatitis Do you scar easily? Pregnant or nursing? Do you bruise/bleed easily?
Are you currently under the care of a physician? If yes, please explain
Microblading is a way of cosmetic tattooing, re-touch procedures may be required. A healing period of 4-6 weeks is required before a touch up procedure can be performed. On a rare occasion, the pigment may migrate under the skin. Procedure of Microblading may be slightly uncomfortable. The pigments will fade. Immediately after the procedure, the pigment can appear 30-50% darker than the desired result. Although extremely rare, there might be an immediate or delayed allergic reaction to pigment. A negative patch test result does not guarantee that you will not develop an allergic reaction after the full procedure. Allergic reactions to anesthetic can occur. Permanent cosmetics cannot be applied if you are pregnant or nursing, or anyone under the age of 18. Infections can occur if aftercare instructions are not followed correctly. There may be swelling and redness following the procedure. You may experience minor bleeding. If you have an MRI scan within 3 months after Microblading procedure, you should notify/discuss with your doctor. Possible scarring may occur, but is extremely rare.
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V-STEAM  CONSULTATION FORM

I agree*
to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I forget to do so
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© 2017 La Ritz ​Spa & Salon