Step 1 of 2 50% Name* First Last Date*Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Main Phone Number*Secondary Phone NumberEmail* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How did you hear about Coral Spa?*What goals would you like to achieve with treatment?* Select All Prevention Maintenance Repair Relaxation Other Please select any past or present health issues that you are experiencing or have experienced?* None of these Apply Arthritis Glandular (thyroid) Urinary Vision/Hearing Heart (pacemaker) Muscular Diabetes Epilepsy Digestive Cancer (past or present) Viral (HIV/Hepatitis) Respiratory Low Blood Pressure High Blood Pressure Headaches Blood Circulation Nervousness Rods/pins/screws/implants Bones/Soft Tissue/Joint Osteoporosis Gynecological Disorders What is your primary complaint?*Is there additional information you would like to add, or anything you would like to explain further?Are you currently pregnant?* Yes No If yes, what is your Due Date? Are you breastfeeding?* Yes No Do you smoke?* Yes No Do you wear contact lenses?* Yes No Do you have Rosacea?* Yes No Do you have wrinkle concerns?* Yes No Do you have scarring concerns?* Yes No Do you have sun damage concerns?* Yes No Have you ever had a fungus infection?* Yes No Current medications?*If none, please indicate "N/A" or "None". Condition it treats:*If none, please indicate "N/A" or "None". Prior or upcoming surgeries*If none, please indicate "N/A" or "None". Do you have any allergies/hypersensitivities to oils or smells? (e.g. aromatherapy)?*If none, please indicate "None". If “yes,” please specify Is there any other medical conditions/information you would like to add? SKINCAREPlease check all that apply.Are you currently having any glycolic, laser or micro-dermabrasion treatments?* Yes No If yes, please specify: Do you have any special skin problems pertaining to the face or body?* Yes No If yes, please specify: Which skincare brand do you use?* Do you sunbathe or use tanning beds?* Yes No Do you use Retin A or any other prescription skincare product?* Yes No Are you currently using any products that contain the following ingredients?* Glycolic Acid Lactic Acid Exfoliating Scrubs Hydroxy Acid Vitamin A Derivatives(Retinol) None What is your primary skincare goal?*Is there any additional information you would like to add?Are interested in getting more information on treatments and products that will help you achieve all of your cosmetic goals?* Yes No I hereby certify that I have read and understand all the questions relative to my health and medical history. I have completed all the information accurately and am aware of no health conditions not specifically mentioned in the case history. I will notify my service provider of any changes in my medical profile and agree that there shall be no liability on the service provider or Coral Medical Health Spa’s part should I fail to do so.I understand the esthetic spa service I receive is for relaxation. If I experience discomfort, I will notify the service provider. I understand any esthetic treatment is not a substitute for medical examination or treatment, and that my service provider does not diagnose, prescribe or treat any illness, and that nothing in the course of the session(s) should be construed as such.I hereby absolve Coral Medical Health Spa, and the attending service provider of all claims and responsibility for any unwanted effects to my health as a result or consequence of esthetic spa service. I agree to the terms of the Coral Medical Health Spa cancellation policy for all scheduled appointments that I fail to keep unless I notify Coral Medical Health Spa at least 24 hours in advance. I understand that if I arrive late for an appointment, I am expected to pay for the full session and any extension beyond the originally scheduled ending time will be at the service providers discretion.I understand that ANY type of sexual harassment/misconduct is absolutely forbidden. This is defined but not limited to the exposure of any body parts in the “bikini area” (unless I am doing a Brazilian/Bikini treatment), inappropriate touching, sexual innuendo’s, aggressive come-ons, comments about my providers physical appearance or comments which would make my provider fearful or uncomfortable. I also understand that failure to adhere to this policy will result in a lifelong ban from the facility. Consent* I have read everything above and understand it. I consent to to allow Signature Reset signature Signature locked. Reset to sign again
