Personal Information

Name

First Name

Last Name

DOB

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

How did you find me?

Emergency Contact (Name, Relationship, Phone)

Health Background & Information

Sex

Female

Male

Transgender

Non-Binary

Prefer not to say

Are you currently taking any medications or supplements?

Yes

If yes, please list name and use:

Do you have computer implants such as a pacemaker, insulin pump or spinal stimulator?

Yes

Do you have any allergies or sensitivities?

Yes

If yes, please explain:

Are you currently pregnant?

Yes

Planning to be

If yes, how far along?

How would you describe your general health?

How would you describe your lifestyle?

Consider: Dietary Habits, Exercise Habits, Rest and Hours of Sleep, Stress Levels, Emotional well-being, Work-Life Balance, and Overall Happiness and satisfaction.

Do you take in high amounts of any of the following?

Caffeine (4+ servings per day)

Nicotine (5+ cigarettes/vape breaks)

Alcohol (7+ drinks per week)

Fast Food (2+ times per week)

Water (64 ounces/half a gallon per day)

Sun exposure / Tanning

Your Skin

What is your Fitzpatrick skin classification?

The Fitzpatrick Classification is a scale that helps determine how the skin responds to sunlight and other face treatments.

Type I: light, pale, white; always burns, never tans

Type II: white, fair; usually burns, tans with difficulty

Type III: medium white to olive; sometimes mild burn, gradually tans to olive

Type IV: olive tone to light brown; rarely burns, tans with ease to moderate brown

Type V: medium brown; very rarely burns, tans very easily

Type VI: dark brown; never burns, tans very easily, deeply pigmented

Have you had any facial aesthetic procedures done in the 6 months?

*NOTE - facial massage cannot be administered if you've had a chemical peel, botox, filler, thread, or any plastic surgery on the face in the last 2 weeks.

Please list anything you are currently doing to take care of your face/skin:

Do you receive facials? Have a skin care routine at home? Taking any supplements? Use SPF? Etc.

Have you ever had buccal massage before?

This means massage inside the oral cavity.

Buccal Massage Discription & Consent

Buccal Massage includes massage of the buccal muscles (cheeks), jaw (TMJ), and surrounding facial muscles. The practitioner will work inside the oral cavity while wearing sterile, nitrile gloves. The results may vary, and the client may feel some soreness/tenderness after the treatment. It is the client's responsibility to disclose if they have had any of the following before receiving this work: recent jaw injuries, cold sores, infections, dental surgery, or Botox/Fillers within the last 4-6 weeks. The client confirms they understand the procedure, understand they have the right to stop the session at any time, and have had the opportunity to ask questions. Please type your name below to confirm you agree to these terms.

What are your goals for this treatment session?

Is there anything else that your therapist should know before your session?

COVID Protocol

Do you now, or have you recently had any respiratory or flu symptoms?

Yes

Have you had a fever in the last 24 hours?

Yes

Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms?

Yes

Would you prefer your practitioner to wear a mask during your appointment?

I have no preference, without is just fine.

Yes, please!

Disclaimers

I understand that the facial massage I receive is provided for therapeutic purposes. I further acknowledge that my practitioner may integrate the use of a Medicupping machine on gentle suction during certain stages of healing, which is intended to assist lymphatic fluid movement and management of scar tissue. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

Please Initial.

I further understand that this bodywork should not be construed as a substitute for medical examination or diagnosis and that I should see a physical or other qualified medical specialist for any medical or physical ailment of which I am aware. Because this type of massage should not be performed under certain medical conditions, I affirm that I have stated all my known conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so.

Please initial.

I understand that, because bodywork involves maintained touch and close proximity over an extended period of time, there may be elevated risk of disease transmission, including COVID-19.

Please Initial.

Please note: It is important that you complete this intake form in full. Certain medical conditions are contraindicated and determine if or when you can receive a session. After the consultation and review of the information you have provided on this form, it will be determined if it is safe to perform any/all facial techniques on you. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being.

The Zen Chameleon and Practitioner, Courtney, reserves the right to refuse, postpone, or terminate treatment whenever we deem it in the best interest of one or more parties.

Please initial.

Release of Records/Permission to Communicate Consent: I hear-by give The Zen Chameleon and Practitioner, Courtney, to communicate with any and all practitioners involved in my treatment as they deem necessary. Please note: We will inform you of this line of communication if/when it needs to take place.

Please Initial.

Cancellation Policy: I agree to pay the full fee of service upon the day of service. I understand if I miss my service and do not give 24 hours notice of cancellation, that I am still held responsible to pay the full service fee.

Please Initial.

Minors: Parents must accompany any minor under 18 years of age to each and every appointment.

Please Initial.

By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner. I acknowledge that this facility and the therapist will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during my session.

Please type your full name.

Social Media Consent & Release Form

I hereby authorize Courtney to use my photo, video and/or information related to my experiences with them and/or The Zen Chameleon. I understand this information may be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, social media and/or other similar ways. Courtney will disclose to me or my legal representative, where appropriate, the specific information and/or photo to be used prior to release in the social media. My consent is freely given as a public service The Zen Chameleon, without expecting payment.

You can opt in or out. To OPT OUT, leave blank, to OPT IN type full name.

I release Courtney and The Zen Chameleon and their respective employees, officers and agents from any and all liability which may arise from the use of such news, media stories, promotional materials, written articles, videotape and/or photographs.

If OPTING IN, please type full name. of OPTING OUT, leave blank.

I prefer that (tick as appropriate):

My complete name may be used

My first name only may be used

No name be used

My instagram handle may be included

Include instagram handle if selected that option above:

I understand that I can revoke this release at any time in writing and that the use of any of my photos or other information authorized by this release will immediately cease.

By typing your full name, this serves as your signature.

Facial Massage Intake Form