Name
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First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone
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Occupation
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Referred by
Emergency Contact
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Emergency Contact Phone
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Have you had a NeoLifting treatment, or similar treatment, in the past? If so, when? Please note if there were any complications.
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Please describe your skin, including any issues or concerns as well as what you like and appreciate about your skin.
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Are you pregnant or breastfeeding?
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Please list any known allergies.
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Please list any medications and / or supplements you are currently taking?
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Are you using any other remedies, such as homeopathy, Bach flowers, herbal or other?
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Please list any current chronic physical or mental health conditions.
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Please list any past surgeries and / or procedures, including plastic surgery and injectables.
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Please choose the best option to describe your current stress level.
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Please briefly describe the activities you engage in for movement, including how often and for how long.
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Please note any of the following conditions apply to you: Systemic contagious or infectious diseases, including the common cold, flu and COVID and 7 days after, COVID vaccination – 14 days after, acute pain anywhere in the body, severe unstable hypertension, fever, nose bleeding, under the influence of drugs or alcohol, including prescription pain medication, recent operations including plastic surgery or acute injuries, benign tumors and various cancers, serious nervous or psychotic conditions such as schizophrenia or psychosis, epilepsy, heart problems, angina, pacemaker, herpes in acute stage, bleeding of the gums, mouth ulcers, pregnancy I and III trimester, unmanaged thyroid dysfunction, autoimmune thyroid dysfunction, thyroid cysts, pathologies of lymphatic system including inflammation of lymphatic nodes, damaged lymphatic vessels, acute rosacea and couperose, skin inflammation, open cuts and wounds, local inflammation of the skin, psoriasis, neurodermitis, eczema, sunburn
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Please note if any of the following conditions apply to you: Excessive emotional excitability, nervous or psychotic conditions (bi-polar and borderline personality disorder, neurosis, depression, grief, extreme stress, history of abuse including sexual etc…), mild rosacea, pregnancy II trimester, post-cancer or cancer in remission, allergies of various aetiology, spinal disk hernias, bulging, thinning or degenerative discs (especially in the neck), 60+ years of age and/or with known conditions affecting bone health, osteoporosis, osteopenia, managed thyroid conditions, Botox in the past 5 weeks, fillers in the 5 weeks, mesothreads and threadlifting within the past 3 months
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Please note if any of the following conditions apply to you: Cardio-vascular system (angina, arrhythmia, pacemaker, arterial hypertension, high blood pressure, varicose veins), kidney (stones, renal failure), liver (gallstone disease, hepatitis), gastrointestinal (stomach or digestive complaints), pulmonary (asthma), nervous system (epilepsy; herniated, bulging discs; neuralgia; bells’ palsy; ramsey hunt syndrome; inflammation of trigeminal / facial nerve; stroke; loss of balance), musculoskeletal system (scoliosis, arthritis, osteoarthritis), endocrine system (acute thireoidtis, nodular goiter, cysts and/or growing thyroid nodules, diabetes), chronical ent disease (ear, nose, and throat), dental conditions (pulpitis, stomatitis, paradontosis, mouth ulcers, dental implants, brackets), cancer / oncology, maxillofacial injures
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Do you ever experience fainting?
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Do you experience frequent headaches or migraines?
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How many hours of sleep per night do you get on average?
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Do you regularly consume caffeine?
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Do you regularly consume alcohol?
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Do you smoke?
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Do you regularly consume carbonated beverages?
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Please briefly describe your eating habits, including how many meals you typically eat in a day, whether or not you eat meat, dairy, eggs, grains and sugar, as well as fresh fruits and vegetables.
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How much water do you drink each day?
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Please note if any of the following apply to you: Lack of confidence, low self esteem, abandonment, panic attacks, indecisiveness, anxiety, mood swings, depression, sadness, grief, fear, anger, frustration, feeling isolated, loneliness, lack of direction, boredom, longing, difficult to make changes, apprehensive, nervousness, highly strung, shy, rejection, guilt, betrayal, lacking energy, lacking concentration, mental fatique, resentment, tearfulness, shock, spaced out, nightmares, jealousy, trauma, unattractiveness, feeling ugly, feeling unworthy, hating myself, abusive relationship, sexual assaults, other
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Please list anything else you feel is important that I am aware of.
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Studio Etiquette
For the best experience, please arrive well-hydrated and at least one hour after your last meal. To support deep relaxation, avoid excessive caffeine—I’ll do the same!
Please arrive approximately 10 minutes prior to your scheduled appointment time to enjoy a leisurely check-in - arriving late will limit the duration of your treatment;
For your relaxation and enjoyment, mobile phones and other electronics are discouraged;
Smoking and consumption of alcohol within the studio is strictly prohibited.
Cancellation Policy
Late arrivals: If you arrive late, your treatment time will be adjusted accordingly, as I cannot extend sessions into another client’s appointment. Arrivals after 20 minutes will be considered a no-show and billed at 100%. Thank you for your understanding!
Cancellations: Your time is valuable, and so is mine. As a solo practitioner, Marma is both my passion and my livelihood, and I kindly ask that cancellations be made with mindfulness and respect. Please provide at least 48 hours' notice if you need to reschedule or cancel your appointment.
If you are feeling unwell or experiencing contagious symptoms, including cold sores, please cancel your appointment. I am not able to provide treatment in cases of illness, and arriving with symptoms will result in a full-service charge. This ensures health and wellbeing for everyone.
Cancellations within 48 hours will be charged 50% of the appointment fee, without exception.
No-shows will be billed at 100% of the appointment fee.
I am unable to provide refunds or credit toward future services.
Please book with care, knowing this policy ensures fairness, clarity, and respect for both of us.
Agreement
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By checking this box, I confirm that the information I’ve provided is true and accurate, and that I agree to the Studio Etiquette and Cancellation Policy.
