Health Waiver Information

Please fill out the following form.

First name

Last name

Email

Date of Birth

Phone#

Address

Have you ever had a spa treatment before? *

No

Yes

Have you ever had any of the following health conditions in the past or present (check all that apply)

Cancer

High Blood Pressure

Eczema

Seizure or Epilepsy

Metal Plates

Skin Disease or Lesions

Keloid Scarring

Have you used any acne medication? *

No

Yes

If you answered yes, please explain.

Do you have any allergies? *

No

Yes

If you answered yes, please explain.

Why are you interested in our service?

Initials

I declare that the info I’ve provided is accurate & complete

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Contact Us

386-517-3241

4750 E. Moody Blvd. Ste 225

Bunnell, Fl. 32110

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