New Patient Form

Personal Information
Name*
First Last
Preferred Name
Title
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone Number*
How do you prefer to be contacted?
How did you hear about us?
Dental Insurance
Employer
Doctor Name
Doctor Phone

Medical History
Do you have any of the following conditions?
Conditions column 1*
- Allergies
- Asthma
- Arthritis
- Back Pain
- Cancer
- Claustrophobia
Conditions column 2*
- Dizziness
- Epilepsy
- Fatigue
- Fibrosis
- Head/Neck Trauma
- Thrombosis
Conditions column 3*
- Allergies
- Headaches
- Heart Disease
- Hepatitis
- HIV
- High blood pressure
Conditions column 1*
- Allergies
- Muscle Pain
- Neck Pain
- Pregnancy
- Skin Infections
- Spinal/disk injury
- Other (write details below)
Details
Have you had surgery in the last 6 months? If yes, what for:
How many glasses of water do you drink per day?
How many cups of coffee do you drink per day?
Do you smoke? If yes, how many per day?
On a scale of 1 to 10 (10 being highest), please rate your level of stress.
How many hours of sleep do you get per night?
Please list any medications you are currently taking:
Have you noticed any irregularities in your skin or hair?
Do you supplement with vitamins and minerals? If yes, what type?
Have you ever consulted a Plastic Surgeon or a Dermatologist? If yes, for what procedure or treatment?
Have you used Alpha Hydroxy Acid (A.H.A.) products on your skin?
Have you ever used Retin A or Acutain? If yes, when, for how long, and what % and pH?
What products are you using on your skin right now?
When was your last aesthetic or body treatment?

Consent*
I agree that the above information is correct. I consent to assume all responsibility to immediately communicate the slightest bit of discomfort or pain during any treatment at Breathe Spa, releasing any and all liability or responsibility to the Therapist and to Breathe Spa. I agree to report a thorough report of my past and current conditions and that the communicating of any discomfort during any point in this treatment has been explained to me, and that failure to do so waives all responsibility to Breathe Spa and to the Therapists.

I also understand that, I assume responsibility for any and all fees associated with the procedures and services.
Yes, I agree*
Cancellation Policy*
To allow sufficient opportunity to accommodate other appointments, we require 72 hours’ notice for cancellations or changes to bookings for:
- Spa Packages or services requiring 2 hours or more.
- Group packages of 2 or more people
- All other services require 24 hours’ notice.
We reserve the right to charge a fee equal to 50% of the cost of service and may request a credit card number or deposit to reserve future appointments.*
All appointments requested online are NOT yet booked. A Breathe Spa Coordinator will contact you to confirm the appointment.
*Please Note: Half of payment is due at booking confirmation when two (2) or more guests are scheduled on the same day, booking any spa package, aesthetic package or holiday package, or any dollar amount over $150.00 before taxes. Prices are subject to change.
Yes, I have read and understand the cancellation policy*
Name*
Signature*
Name
This field is for validation purposes and should be left unchanged.

Personal Information

Medical History