Today's Date

YYYY

First and last name

First Name

Last Name

Email Address

Phone

(###)

###

####

Date of birth

Explain the changes you would like to see in your skin.

(i.e. less redness, reduced texture, fine lines, reduction in larger wrinkles, purely preventative)

Let's get to know your skin a bit better. Describe your skin when you first wake up in the morning.

(i.e. is it bright and clear, is it dull and pale, does it feel dry or oily, does it feel tight?)

How does your skin behave during the month compared to your cycle?

Current AM skin care routine.

Please include product names and brands along with the order you apply it. If you wear makeup, please include primer and foundation routine as well.

Current PM skin care routine.

Please include product names and brands along with the order you apply it.

How often do you wear sunscreen? What level of SPF do you wear and what brand?

Tell us about your average daily diet.

Get specific! What time do you generally eat breakfast, lunch, dinner and snacks? What fats do you cook with? Which foods do you most crave? Which foods do you eat least?

Tell us about your beverage consumption.

How many ounces of water do you drink daily? What is your average number of alcoholic beverages per week? Do you drink tea/coffee/soda during the day? What times and how often? How about juices or smoothies?

Help us understand your lifestyle.

How often do you travel? Rate your current and past levels of daily stress. What are your go to stress relievers?

Do you have sleep issues?

Are you fast to sleep or do you find it hard to fall asleep? Do you wake up in the middle of the night or early in the morning?

Do you have any known allergies?

Do you smoke?

Quantity per day.

Are you on any medications, prescription or over the counter including supplements?

Please list and describe frequency of each.

Have you have botox, fillers or a chemical peel?

Please list all that apply and the dates last performed for each.

Whew! You did it and we are so grateful. Is there anything we missed that you want to share?

Do you have any health issues such as a pacemaker?

Please list any and all issues down below.

How did you hear about reishi? We would love to say thank you!

Informed Consent

Voluntary Consent I hereby voluntarily request and consent to be treated, or give permission for my child/ward to be treated, with a facial, advanced exfoliation, acupuncture; electro-acupuncture; acupressure and other techniques based on Traditional Chinese Medicine. I understand I may be given recommendations on diet, lifestyle and nutritional or herbal supplements and it is my decision whether or not to follow these recommendations. The procedures involved in this treatment have been explained to me. I understand I may be treated with the insertion of needles or other non-insertion techniques; electrical stimulation; or touch/palpation. I have not been guaranteed any success concerning the uses and effects of these treatments. I understand that I am free to discontinue treatment at any time. Possible Side Effects/Healing Reactions I understand that these treatments may result in certain side effects, including local bruising; slight bleeding; fainting; temporary pain or discomfort; and temporary aggravation of symptoms existing prior to treatment. Unusual and rare risks of acupuncture include nerve damage, organ puncture, and infection. I have read the information on this page and understand the possible risk involved. Medical Referral I understand that I should consult a licensed physician for appropriate medical evaluation and treatment of the conditions for which I am seeking acupuncture treatment. Treatment from this practitioner does not substitute for appropriate medical treatment by a licensed physician. I have been advised that if there is a worsening of my ailment or condition, or if it does not improve within the time estimated by the acupuncturist at the beginning of treatment, or if a new ailment or condition arises, I should again consult a licensed physician. If I am presently under the medical care of a physician, I have been advised to continue all medications and treatments as prescribed until such time as my physician deems it appropriate to reduce or discontinue the medications or treatments. I certify that I have informed The practitioner of all known physical, mental, and medical conditions and medications, including possible pregnancy, and that I will notify The practitioner of any changes. Infectious Disease/Clean Needle Procedures I understand that there is infectious disease carried through the air, through physical contact, and through body fluids. I understand that universally prescribed precautions will be utilized during treatments to guard against the spread of infection, including the use of sterilized, prepackaged disposable needles. Needles that are used for my treatment are used only on me, and are inserted according to clean procedures based on nationally prescribed standards. Needles are disposed of as medical waste immediately after use. I understand that my questions about the safety of any procedure or treatment or the precautions taken by the practitioner are most welcome and will be answered as fully as possible. I understand I have the right to refuse any treatment or procedure. I have read this form carefully. I have felt free to ask any questions, and it has been satisfactorily explained to me. Payment and Cancellation Policies  Full payment is expected at the time services are rendered. We accept checks, credit cards, and cash. If you must cancel or reschedule your appointment, we require 24 hours notice to avoid a cancellation fee. Please note that any cancellation fee is the responsibility of the patient. I have read and understand the above, and I agree to be treated.

I Agree