Your Name (required) Your Email (required) Date (required) Your Mobile Phone (required) Where are you staying in Tulum? (required) Date you are leaving? (required) Are you pregnant? (required) NoYes (If yes, How many weeks?) Have you ever had a negative reaction to any skin care product and/or natural herb or essential oil? NoYes (If yes, please describe) Do you have any allergies? NoYes (If yes, please describe your allergies) Do you have any skin conditions or breakouts you are concerned about? NoYes (If yes, please describe) Do you have any of the following medical conditions? (required) high/low blood pressurecontagious diseasespinal problemsheart problemsvaricose veinsarthritispacemakerdiabetescirculatory conditionjoint pain/inflammationphlebitisheadaches/dizzinessepilepsy/seizuresnursingasthmaclaustrophobiaarteriosclerosisfoot funguscancernone In the last 7 days have you experience any of the following symptoms? FeverCoughHeadacheDiarrheaVomitingChillsStomach painMuscular PainJoint painWeaknessRunny NoseSore ThroatConjunctivitisnone Do you have any other diseases or medical conditions? NoYes (If yes, please describe) Have you had any medical or cosmetic procedures? NoYes (Please describe with date?) Have you had any recent surgeries or operations? NoYes (Please describe, and when was your most recent procedure?) Please list any additional comments regarding your skin care or general health MASSAGE OR BODY THERAPY: Please mark with an X areas in need of attention.
