Salon Secrets Spa Massage and Facial Waiver Date Your Name Birthdate Address Street City State Zip Phone Number Email Emergency Contact General Health Questionnaire (check all that apply) Massage Pregnant High blood pressure Tension or soreness in a specific area Facial Current skin conditions (allergies, psoriasis, warts, poison ivy, etc.) Sinus problems, seasonal allergies Headaches, migraines, tension Do you have any other medical conditions? Yes No Explain Are you currently under the care of a physician/naturopath/homeopath? Yes No Explain Do you have any allergies to food or medications? Yes No Explain Are you currently on any medications, either topical or oral? Yes No If yes, please list List any surgeries in the last six (6) months or conditions for which you have been hospitalized, including broken bones I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the provider updated as to any changes in my medical profile and understand that there shall be no liability to Salon Secrets Spa should I fail to do so. Client Signature
