FACIAL GUEST CARE FORM PROMISE TO YOU
If you’re not happy with our service for any reason we will reschedule a second visit at no charge or issue a full refund along with our sincerest apologies!
PERSONAL INFO Client Name: ______________________________Therapist: _______________________________
Client Address: _____________________________City:________________ State:_____Zip: ______
Cell Phone: ________________________________E-mail:_________________________________
Birthday: Month_____________ Day______ Anniversary: Month___________ Day_______ MEDICAL HISTORY
Do you have any health concerns your therapist should know about?____________________________
Are you pregnant?_________________________________________________________________
Do you have any allergies or sensitivities to products?_______________________________________
Do you have any special concerns pertaining to your face or body? S Yes S No If yes please specify?
______________________________________________________________________________
Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments? S Yes S No
Do you use Acutane, Retin A, Renova, Adapalene or any other prescription skin products? S Yes S No
Are you currently using any products that contain the following ingredients?S glycolic acid S lactic acid S any hydroxy acid product S vitamin A derivatives (i.e. retinol) S any exfoliating scrubs
Do you consider your skin to be sensitive? S Very S Somewhat S Not usual y
It’s always a good idea to use the restroom before the service! FACIAL POLICY
Please be advised that a one hour facial session includes: 5 minute initial set up client comfort time, 50 minute actual facial time and 5 minute after session client comfort zone. I hereby consent to the above–mentioned treatment and assume all risk of personal injuries. I voluntarily release Red & White Spa from
any and all liability claims, or actions which may be related to any treatments received. IMPORTANT
Please ask the Aesthetician within 10 minutes of the start of the facial to STOP if you are not happy with the service. At that point we will gladly reschedule a second visit or issue a full refund with our sincerest apologies. However, after 10 minutes we will NOT be able to reschedule or offer a refund. Initial:_____________
Client Signature: _____________________________ Date: _____________________________
SPA USE ONLY Comments / Remarks____________________________________________________________________________
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Service Provider Name__________________________________
MEDPHARM NON FDA PRODUCT LIST (EUROPEAN ORIGIN) THERAPEUTIC CAT PROD CODE GENERIC DESCRIPTION QUANTITY ANALGESICS, ANTIPYRETICS, ANTI-INFLAMMATORY, ANTIRHEUMATIC DRUGANTIALLERGICS AND DRUGS USED IN ANAPHYLAXISepinephrine (adrenaline) 1 mg/ml 1 ml (two end)ANTIALLERGICS AND DRUGS USED IN ANAPHYLAXISalbendazole 400 mg chewable peppermint flavouredalbendazole 400 mg chewable pe
DRAFT SCHEDULE** (Times and Speakers Subject to Change) Marriott World Center SCHEDULE-AT-A-GLANCE THURSDAY, May 17, 2012 PRE-CONFERENCE WORKSHOPS: REGISTRATION OPENS 9:00 am – 6:00 pm Putting it all Together: The Nuts and Bolts of Sangeeta Pati, MD Hormone Restoration in Men and Women 9:00 am – 5:00 pm Transforming Theoretical Into Practical: A Lena Ed