Consultation FormConsultation Form Name* First Last Address* Address City State Zip Email* Phone*Gender* Female Male I prefer not to shareBirthday* MM slash DD slash YYYY I would like to receive the informative monthly Osmosis newsletter* Yes NoMedical ConditionsPlease check any of the following that apply to you in the last 2 years:Conditions Arthritis/tendinitis Auto-immune disease Blood clots Stroke Circulatory/heart problems Communicable diseases High / Low Blood Pressure Bruise Easily Cancer Edema OtherPlease indicate Other Condition hereAre there any conditions that you would like to share, in confidence, with your service providers?Are you pregnant? Yes NoIf so, how far along?AcknowledgementsPlease check each box to confirm you've read each statementAgreements The Cedar Enzyme Bath is a high heat treatment and is not recommended for those who are pregnant, have high blood pressure or uncontrolled diabetes. If I experience pain, discomfort or overheating during the session, I will immediately inform my therapist so that my comfort level can be adjusted. I affirm that I have notified my therapist of all known medical conditions and injuries. I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. In the event that I become injured either directly or indirectly as a result , in whole or in part, I hereby hold the therapist and Osmosis harmless and indemnify their principals, and agents from all claims and liability whatsoever. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Massage, Cedar Enzyme Bath and Facials (including peels and waxing) should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.Cedar Bath QuestionsComplete this section if you are receiving a Cedar BathWill you be receiving a Cedar Bath? Yes NoDo you have high blood pressure or uncontrolled diabetes? Yes NoDo you have any allergies to Cedar, Douglas Fir, Rice Bran or Lavender? Yes NoMassage QuestionsComplete this section if you are receiving a MassageWill you be receiving a Massage? Yes NoAre you currently under a physicians care for an acute or chronic illness? Yes NoAre you currently taking any prescribed medication? Yes NoWhat Medication?Please list any recent injuries or surgeries within the past 2 yearsAre you allergic to any oils, lotions or essential oil scents? Yes NoFacial QuestionsComplete this section if you are receiving a FacialWill you be receiving a Facial? Yes NoWhen was your last Facial?When was your last Peel?When was your last Waxing?Check any recent: Chemical Peel Laser Microdermabrasion Electrolysis Facial Surgery or Injection SunburnCheck any that apply: Contacts Cancer Claustrophobic Heart Condition Diabetes Cold SoreDo you have any allergies or sensitivities? Yes NoPlease describe your allergies or sensitivitiesDo you take any medications? Yes NoPlease describe your medicationsDo you use any topical or oral acne products? Yes NoPlease describe your topical or oral acne productsDo you use any glycolics, retinols, or AHAs? Yes NoPlease describe your glycolics, retinols, or AHAsHow would you describe the texture of your skin? Oily Dry CombinationSkin Texture DetailsDo you experience frequent breakouts? Yes NoDescribe your breakoutsCheck any concerns: Wrinkles Firmness Dullness Hyperpigmentation Sun Damage Uneven Skin Tone Dry Oily Breakouts Clogged Pores Large Pores Sensitivity Redness Rosacea Broken CapillariesCommentsAny other commentsΔ