Your name

Your email

Your Phone

Do you have any plant, food or nut allergies?
YesNo

If Yes, please list:

Are you under the care of a doctor for a current condition?
YesNo

Are you pregnant?
YesNo

Have you had fillers or Botox?
YesNo

Is so, how long ago?

Do you have any metal in your body?
YesNo

Fillings or implants in your mouth?
YesNo

Please list any medications you are on, oral or topical:

Are you or have you ever used (please check):
AzelezDifferinRenovaRetin-ATazoracGlycolic or alpha hydroxy acid (AHAS)Accutane

If so, when and for how long?

Do you have or are you affected by any of the following?
Asthmacardiac problemseczemaepilepsycold soreschronic headacheshepatitisherpeshigh blood pressurehysterectomyimmune disorderlupusfibromyalgiapacemakersinusurinaryskin diseasesdiabetesmentalimplantsmitral valve prolapse

(Required) I understand that withholding information or providing misinformation may result in contraindications, and or irritation to my skin from the facial massage or LED treatment received. The facial massage or LED treatment I receive here is voluntary and I release Stepping Into Wellness, LLC from liability and assume full responsibility thereof. By accepting this free session I agree to subscribe the marketing communications from Stepping Into Wellness. I understand that I may opt out from marketing communications at any time.

(Required) I understand that certain medical conditions such as: autoimmune disorders, diabetes, epilepsy, melanomas, metal implants including plates/pins/screws, open wounds, pacemakers, electrical implants, pregnancy, thrombosis, and varicose veins are contraindicated with microcurrent treatment and should not be performed if I have any these conditions.

(Required) I understand that I may experience a slight tingling sensation, flashing of the optic nerve or a metallic taste in my mouth during the procedure.

(Required) I agree that I have fully disclose my health history honestly to the best of my abilities. Prior to receiving treatment I have been candid and revealing any and all medical history under conditions that may have bearing on this procedure.

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