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Facial Cup After Care
**This New Client form is for anyone
requesting an appointment with Gary for the first time. Please take the time to fill out completely.
New Client Form
Do you have a Gift Certificate or Voucher
Finding Source Gift Certificate
Full Name of Person who purchased your Certificate or Voucher
*Groupon - 8 digit bar code number (ex. 1234-5678) usually located in the top third of the printed voucher page *Living Social - Located in upper right hand corner of printed page
Full name of your Referral (Type N/A if you do not have one)
If you have a Groupon or similar voucher or do not have a referral then just put N/A in this line.
Are you Pregnant?
Gary's massage style is not suited for pregnant women unless you are beyond the 40 week mark, then Reflexology, Facial Cupping, Vibrational Tuning and Consultations are only available
Do you have any Medical conditions/ chronic problems?
If No - Type: NONE - If Yes please give a brief description *Example: Bulging Disks lower back, Stiff Neck, Insomnia or Trouble sleeping
Please list all medications you are taking
If No - Type: NONE - If Yes please give name and what it is for *Example: Lipitor - cholesterol, Ambien - trouble sleeping
What type of session do you want?
Facial Cupping - A Natural Facelift
Myofascial Decompression (Targeted Cupping 30 min)
Need to Discuss
If you are not familiar with Gary's style of work or have specific medical issues then just choose the "Need to Discuss" option
Do you require a Full Consultation prior to your session? *NOTE: Some promotional vouchers do not include the Full Consultation, however can be added on for a nominal fee. Please check with Gary when scheduling.
No - Just the Basics Please
As a new client Gary will sit down with you to gather information about your health prior to your time on the table. This is required for all new clients at no extra charge. This can last from 15 minutes to and hour depending on your needs. If you have medical conditions or chronic issues of any kind Gary can research your condition before you come in and offer options for self correction as a part of your initial session. However if you are in good health Gary can just cover the basics in the pre-session consult.
Do you prefer a specific day or time of day? Check all that apply
Early - 10:30 am to 1pm
Mid afternoon - 1pm to 4pm
Late Afternoon/Early Eve - 4pm to 7pm
Saturday - 11 am to 4
*Note - During Peak times, late afternoon and weekends fill up first, so if you have a little flexibility you can usually get in quicker with daytime options
Please request specific dates/times here:
Additional requests, comments or questions here:
- Pain Management
- Pain Elimination
- Self Empowerment
- Self Reliance
- Greater Health & Vitality
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