First Name Last Name

Street Address Apt/Unit Number

City State Zip Code

Home Phone Cell Phone

Email used for confirmation purposes

Birthdate Profession

Are you pregnant? Yes No If yes, due date

How did you hear about us? A Client Who? A Postcard SPA Finder City Search Advertisement Website Walked By Other Who/What/Where?

Do you eat a balanced diet? Yes No

Rate your general consumption of the following:

Alcohol

Heavy

Moderate

Light

None

Caffeine

Heavy

Moderate

Light

None

Tobacco

Heavy

Moderate

Light

None

Sugar

Heavy

Moderate

Light

None

Please check any of the conditions you may have:

circulatory problems

heart disease

contagious disease

spinal problem

respiratory problems

arthritis

blood clots

carpel tunnel

low blood pressure

high blood pressure

muscular injury

diabetes

Other

Please check any chronic symptoms you have:

abdominal pain

digestive problems

fatigue

sinusitis

depression

dizziness

constipation

insomnia

chestPain

migraine headache

Other

Do you wear: contacts dentures prosthesis Other

What special skin problems do you have pertaining to your face or body?

Have you ever had chemical peels, microdermabrasion or any other resurfacing treatments? Yes No

Do you use Accutane, Retin A, Renova, Adapalene or any other prescriptions for skin conditions? Yes No

Do you experience breakouts? Yes No

If yes, Where? Hairline Forehead Under Eye Chin Cheeks Jawline

Do you experience oily shine during the day? Yes No

Do you have a tendancy towards redness? Yes No..........Do you blush easily when nervous? Yes No

Do you experience a burning, itching sensation on your skin? Yes No

Do you ever experience these conditions on your skin? tightness flakiness obvious dryness

Do you suffer from sinus problems? Yes No

Have you ever had a reaction to any of the following: cosmetics medicine iodine pollen food
hydroxy acid animals sunscreen Other

How much water do you consume daily?

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Have you ever had a massage before? Yes No If yes, when was your last massage?

Primary reason for massage? Stress Reduction Muscular Tension Relaxation Other:

What is your occupation? Rate your stress level: 1(low) to 10 (high)

List your primary areas of discomfort or tension:

Do you exercise or regularily participate in sports? Yes No

If yes, describe activity and frequency:

Cancellation Policy

Because Tranquility Day Spa is by appointment only, your appointment time is reserved exclusively for you and we request that you acknowledge and respect our cancellation policy.

If you need to reschedule or cancel an appointment, we require a minimum of 24-hours notice (Spa Party services require a 72-hour notice). If you need to cancel your appointment you need to call the spa at (617) 924-1026. If we do not answer, leave your information on our answering machine.

Please keep in mind that no cancellation, no-shows or last minute cancellations leave our therapists with empty appointment times as well as other guests that can not get in. Because of this clients that do not honor their appointments will be charged a cancellation fee as follows:

• More than 24 hour notice. Service will be cancelled at no charge
• Less than a 24-hour notice of cancellation will be charged 50% of the service price.
  • Spa party services cancelled, in full or in part, will be charged 60% of the service with less than a 72-hour notice.
• Failure to show without notice, 100% of the service price will be charged.

Cancellations by email are not accepted.

I have read and understand the cancellation policy.

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Our Limitations

Our therapists do not diagnose illness, disease or any other physical or mental disorder. Our therapists do not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulation. It is very clear that treatments provided are not a substitute for medical examination or diagnosis and that it is recommended that a physician be seen for any physcial ailment that you may have.

I have read and understand the limitations and I have stated all of my known medical conditions and take it upon myself to keep the therapists updated on my physcial health.

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