Stonebriar Spa

Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Birthday (year not required):
Please provide email address if you would like to receive our Preferred Client newsletter with special offers:

We do not sell or share our email list. Emails are only sent out once or twice a month.
Reason for visit:
Preferred massage pressure *
light - medium medium - firm very deep
Please specify type and date of surgeries you have had in the last year:
List any medications you are currently taking:
Please list any medical condition(s) including allergies that we should consider when providing services:
Please choose any problematic conditions that apply to you:
arthritis asthma back problems blood clots blood pressure broken bones bruise easily cancer carpal tunnel claustrophobic contact lenses depression diabetes epilepsy fever foot problems headaches HIV/AIDS osteoporosis phlebitis pregnant rotator cuff rashes sciatica scoliosis smoker stress TMJ trauma (accident) varicose veins sensitivity to cold, heat or pressure
FACIAL & WAXING CLIENTS ONLY
Which have you used in the last 6 months? *
Accutane Retin A Renova Other prescribed medication none
Have you ever had reactions to any of the following? *
Pollen Cosmetics Food Medicine AHA's Fragrance Other None
Do you experience oily shine during the day?
yes no occasionally
Do you experience skin breakouts?
yes no occasionally
Do you experience any of the following?
Oiliness Dryness Flakiness Tightness
Do you have any specific skin concerns?
Please indicate products that you are currently using on your face:
Soap/Cleanser Toner Mask Moisturizer Sunscreen Scrubs/AHA/Peels Other
Do Not Fill This Out