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Facial Cup After Care
**This New Client form is for anyone
requesting an appointment with Gary for the first time that requires a Full Consultation. Please take the time to fill out this form completely.
New Client Form w/Consultation
Indicates required field
Do you have a Gift Certificate or Voucher
Finding Source Gift Certificate
Groupon/ Living Social
If you purchased from Groupon/Living Social or Gary's New Client Offer which option did you buy?
1 Hour Session
90 Minute Session
Full Name of Person who purchased your Certificate or Voucher
Voucher/Certificate Number **NOTE: Groupon/Living Social Customers - You cannot be scheduled without this number
Please include voucher numbers for proper verification
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, However Reflexology, Facial Cupping, Vibrational Tuning and Consultations are 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
What type of session do you want?
Facial Cupping - A Natural Facelift
Myofascial Decompression (Targeted Cupping 30 min)
Axiatonal Integration - Please allow 2+ weeks to schedule
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 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:
Preliminary Questions for your Consultation
1. Do you have a specific goal in mind for your Consultation? (examples: Eliminating chronic pain, Getting off of my medications, etc.)
2. List all Medications by name that you are on and what they are prescribed for: (example: Lexapro – For Anxiety)
3. What nutritional supplements do you take? (example: Multi-vitamin/Mineral, Vitamin D, C, Specific herbs etc.)
4. What does your diet generally consist of? (example: Conventionally grown food, Organic Food, Fast foods? Or combination of all 3?)
5. Do you have any sleep issues? How often do you wake up fully rested and refreshed? (example: 25% of the time, 50% of the time, 75% of time, etc...)
6. Do you get at least 4 standard size (16.9 oz) bottles of water everyday?
7. If you are trying to alleviate any specific issues with your health what are they and are any of these issues debilitating or limit you in any way?
8. How often do you get massaged, or get alternative treatments such as reflexology, energy healing etc.
9. List anything else that may be of importance to your consultation here:
- Pain Management
- Pain Elimination
- Self Empowerment
- Self Reliance
- Greater Health & Vitality
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