Guest Info

Name Date of Birth
Email Phone
Address
How did you hear about us? Who referred you?

Medical History

What are some of your specific concerns?

Skin:
Body:
Massage:
Hands & Feet:

Are you currently using Retin A/Alpha Hydroxy Acids? Yes No
Women, are you pregnant? Yes No   How many months?

I declare that I am with full legal capacity and physical condition to utilize the spa facilities and I do it with full knowledge, understanding and appreciation of risks implicated therein. I hereby acknowledge and agree to use the facilities and/or treatments of the spa with the understanding that the possible risks and/or injury and/or disease which I sustain personally will be my full and complete responsibility. By checking "I Agree", I release The Spa as well as all of its employees.