Intake Form _Facial Massage

By checking this box, I confirm that the personal and medical information provided in this intake form is accurate to the best of my knowledge. (Required)

By checking this box, I understand the following contraindications that would require a doctor's note to have treatment:

Medical restrictions (consult a doctor):

• Heart conditions/pacemakers (avoid electrical tools)

• Epilepsy (avoid certain lights/simulations

• cancer treatments

• recent cosmetic surgery or injections

(Required)

By checking this box, I agree to inform the massage therapist of any changes in my health or medication before my session starts. (Required)

By checking this box, I understand that I am receivign a facial massage that includes, but is not limited to cleansing, exoliation, and a specialized massage of the face and neck. The purpose is to e=enhance skin health, promote relaxation, and increase circulation.

By checking this box, I understand that while facial massage is generally safe, possible risks include, but are not limited to, temporary redness, skin sensitivity, or allergic reactions to oils or lotions. I understand that the therapist does not diagnose illnesses, prescribe medications, or treat skin conditions, and that this service is not a substitute for medical or dermatological care. (Required)

By checking this box, I understand that the massage therapist is not an esthetician. Therefore, the therapist cannot perform chemical peels, manual extractions, microdermabrasions, micro-needling, or waxing. Only estheticians can analyze skin, apply professional-grade products, and use advanced tools like ultrasound, high-frequency devices, and steamers.(Required)

By checking this box, I understand that all personal, medical, and health related information shared with Revival of Hope Wellness is strictly confidential. Your "Protected Health Information" (PHI) includes your medical history, treatment notes, and contact details. My information will not be shared with, sold to, or discussed with any third consent unless legal circumstances by law is enforced. (Required)

By checking this box, I agree to the Revival of Hope Wellness cancellation policy I understand that missing appointments without a 48 hour notice may be subject to a cancellation fee. (Required)

By checking this box, I understand that by receiving services in my home/office, I am responsible for providing a safe and clear environment for the massage therapist to work. I am also responsible for providing a bathroom that has hot water for the massage therapist to properly prepare for the service including washing of hands. I release Revival of Hope Wellness from any liability related to the workspace provided.(Required)

By checking this box, I understand that any illicit or suggestive remarks or advances made by the client will result in the immediate termination of the session, and I will be liable for full payment. (Required)