Vascular Disease Heart Problems Hypertension
Hemorrahage Epilepsy Kidney Problems
Implants Joint Pain Take Fiber
Menopause Restricted Diet Improper Diet
Indigestion Pacemaker Redness, Swelling, Heat, Pain
Skin Infection or Ulcerations Migraines / Headaches Menstrual Cramps (PMS)
Hormone Imbalance Muscle Problems Appetite Suppressant Meds
Spine Pain Overweight Take Multi-Vitamin
Snack Between Meals Crave Sweets Health Club Member
Infectious Bone or Joint Cancer Thyroid
Low Energy Smoke Sinusitis
Please Answer the Questions Below:
Yes No
Yes No
Yes No
Yes No
1-2 3-5 6 or more
0 1-2 3-5 6 or more
Yes No
Yes No
Yes No
Light Firm
Skin Care
Yes No
Yes No
Yes No
Mark all that apply
Flakiness Rosacea
Acne Tightness
Oiliness Dryness
Hyperpigmentation Other
Cleanser Exfoliation Moisturizer
Mask Sunsscreen Other
Yes No
Yes No


I affirm that I have stated all my medical conditions and medications. I have answered all the questions honestly. I agree to indemnify, and hold harmless Spa Therapy Wellness Center and Therapist(s) from and against any and all claims, demands, loss or liability of every nature, for injuries to person and/or property. I agree to keep Spa Therapy updated in the event that my medical condition changes. You will be requested to update your health information record every two (2) years. I consent to care by Spa Therapy professional staff and have read and understand consents that apply to my service.

If I fail to keep an appointment by neglecting to cancel my appointment with 24 hours, I will pay Spa Therapy 100% of the fee for the missed appointment. I acknowledge that I am ultimately responsible for payment in full for all services, whether billing is performed or not. I am of lawful age and have read and fully understand the consents of this document and the complete terms and conditions between parties and no other guarantees or refunds will be given on products or services.

Contact us directly if we can offer any additional service.
Call 530-751-5166  -  Fax 530-751-1575

address: 1528 Plumas Court, Yuba City
or email

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