Spa Services Form & Consent 
An accurate health history is important to ensure that it's safe for you to receive treatment. All information is confidential.  Please complete entire form.
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Email *
First Name
Last Name
Mailing Address
Preferred Phone Number
Sex
In the past 48 hours have you done the following? *
What medications are you taking?
What types of allergies do you have?  *
Medical History: (Check boxes where applicable)
Do you have an Medical Instruments ( examples: pacemaker, artificial heart or Lung) *
Have you ever had a facial treatment , body waxing or Lash extensions?  
Have you ever had a reaction to a cosmetics, skin care, lash glue or waxing products? Please describe:
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I release Pure Eden Salon & Spa, and staff of Pure Eden Salon & Spa, from any and all liability associated with any injuries and/or current or future conditions resulting from the services procedures or products.  (Please type your name for agreement.) *
Please read and check if you consent: 

I hereby give my consent for massage, body or esthetic treatment.  I understand that the information provided will be held in the strictest confidence and is used to help formulate an individualized treatment plan.   My service provider will explain possible risks and side effects to me.  I am aware that I may end or alter the treatment at any time.  I am aware that none of the information will be shared with a third party outside of the spa without my written consent.  

I understand that providers performing services on me will review this information.  I also give consent to my provider to speak to any of my other health care providers if necessary.  I am aware that I may withdraw this consent at any time. I understand that in accordance with the "College of Massage Therapists" my records must be kept for a period of ten (10) years.

I understand that the information gathered here is to ascertain allergies, drug products and injuries that may conflict with the ingredients or procedures used during my treatments.
I agreed to the preceding statements on:
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