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Wellness House
AZURE
Our Rituals
Facial Rituals
Body Ceremonies
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First Name
Last Name
Phone Number
Email Address
Date of Birth
Month
Day
Year
Emergency Contact ( Name & Phone Number )
Do you have any allergies or sensitivities?
Do you have any current or past medical conditions we should be aware of?
*
None
Cancer or history of cancer
Heart condition
Diabetes
Epilepsy or seizure disorder
Autoimmune condition
Other
Do you have any implanted medical devices or metal implants?
No
Pacemaker
Metal implants
Titanium plates / screws
Other
If yes, please specify the type and location of implant:
Are you currently pregnant or breastfeeding?
Yes
No
Have you taken Accutane (Isotretinoin) within the past 12 months?
Yes
No
Have you recently received any aesthetic or medical procedures?
Yes
No
Please include the treatment and date:
What would you like to focus on during your ritual?
Hydration
Relaxation
Glow
Firmness
Sensitive skin support
Body renewal
Stress relief
Is there anything you would like us to know to make your ritual more comfortable and meaningful for you?
COMPLETE
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