Upper Body Therapy Form

First and Last Name

Date of Birth

Month

Day

Year

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Country/Region

Address

City

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Medical Information: Please check any of the following that apply to you:

Pregnant

Nursing

Skin Allergies

Allergies to specific ingredients or products:

Medical conditions:

Recent facial or upper body surgeries or treatments:

Other medical concerns:

Concern or goals:

Consent and Agreement

I understand that the Upper Body Therapy is not a substitute for medical treatment or advice. I have provided accurate information to the best of my knowledge.

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Date

Month

Day

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Upper Body Therapy Form

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