BODY SCRUB CLIENT FORM
Today’s Date: _________________
Full Name: __________________________________________________ Date of Birth: _______________________
Address: _______________________________________________________________________________________
City: _____________________________ Province: ___________________ ZIP/Postal Code: ___________________
Phone #: ______________________ Occupation: _______________________ Email: _________________________
Male: ____ Female: ____ Emergency Contact: _______________________________ # _______________________
Please indicate if you are affected by or have any of the following:
Abrasions Herpes
Any known Allergies High Blood Pressure
Any Metal Pins or Plates Inflamed Nerve
Asthma Lupus
Bruise Easily Metal Bone Pins or Plates
Contagious or Infectious Diseases Nervous/Psychotic Conditions
Cuts Osteoporosis
Cancer Pace Maker
Dermatitis Pregnancy
Diabetes Recent Chemical Peel Procedure
Diarrhea or Vomiting (within last 48 hours Recent Surgery/Operations
Eczema Rosacea Sinus Problems
Epilepsy Skin Diseases
Fever Sunburn
Hematoma Urinary or Kidney Problems
Hepatitis Vascular Lesions
Have you ever experienced a scrub before? Yes No If Yes, when was your last scrub? _________________
Are you sensitive to touch or pressure in any area? Yes No If Yes, please list sensitive areas: ___________
_______________________________________________________________________________________________
Do you have any numbness or stabbing pain? Yes No If Yes, please explain: _________________________
_______________________________________________________________________________________________
Do you suffer from backpain? Yes No If Yes, please explain: ______________________________________
_______________________________________________________________________________________________
Do you have any allergies? Yes No If Yes, please list all allergies: ________________________________
_______________________________________________________________________________________________
Please list all prescriptions and non-prescription medication along with any vitamins, herb supplements, that you are
currently taking: _________________________________________________________________________________
Please list all medical conditions you have been diagnosed with for the past 2 years: __________________________
_______________________________________________________________________________________________
Have you had any injuries, accidents or surgeries for the past 2 years? Yes No If Yes please give description
and dates: ______________________________________________________________________________________
_______________________________________________________________________________________________
Have you had a Chemical Peel, Injectables, Botox, Laser Treatments or Microblading in the past 2 years? Yes No
If Yes please give description, dates and details: _______________________________________________________
_______________________________________________________________________________________________
