Name *

First Name

Last Name

Phone (Optional)

(###)

###

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How may we pamper you? *

Express Facial

Calming Massage

Foot Massage

Waist Laser Lipo

Unsure/Undecided

Do you have any known allergies to foods, medications, or environmental factors? *

Yes

No

Are you currently taking any prescribed or over-the-counter medications, including vitamins and supplements? *

Yes

No

How would you describe your skin?

For facial services

Normal

Oily

Dry

Combination

Unsure

Would you like to add facial waxing services?

(Brows, Upper lip, Chin)

Yes

No

Have you ever been diagnosed with a serious medical condition that might be contraindicated for massage or body contouring?

If unsure, please call 404-965-0633 with questions.

Yes

No

Unsure