First name

Last name

Email address

Are you a new customer?
I am a new customerI am a returning customer

[group new-customer]

Emergency contact name

Emergency contact phone number

Medical Information

Are you taking any medications?
YesNo

[group medicationsgp]
If yes, please explain.

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Do you have any allergies or have you ever had an allergic reaction to any skin products or cosmetics?
YesNo

[group allergiesgp]
If yes, please explain.

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Please indicate if any of the following apply to you:
CancerHeadaches/migrainesArthritisDiabetesHigh/low blood pressureDermatitisHepatitisEpilepsyPacemakerTMJ (Temporomandibular Joint)None of the above

Explain any conditions you have marked above:

Are there any other conditions that are not listed above or any medication you take that we should be aware of?

Have you had any of the following?
MicrodermabrasionDermaplaningBotoxLaser resurfacingChemical peelsMicroneedlingElectrolysisCollagen injectionNone of the above

[group previoustreatmentsgp]
If yes, please explain.

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Have you taken Acuutane within the past of 12 months?
YesNo

[group acuutanegp]
If yes, please explain when.

[/group]

Have you used Retin-A, Renova, or any alpha hydroxy acids within the past three months?
YesNo

[group alphaacidsgp]
If yes, please explain which one and when.

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Waxing precautions

You must wait a minimum of seven (7) days before waxing after a light chemical peel or microdermabrasion. Waxing cannot be performed if you have had laser skin resurfacing within the past year. Waxing cannot be performed if you have had a physician administered peel within the past two (2) years. Sunburned, irritated areas, cold sores, and moles cannot be waxed. Due to water retention and for your own comfort, you should avoid genital hair removal two days before your cycle to two days after it is completed. Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read and agree to the above statement.

Liability waiver

1. I hereby acknowledge and agree that Colibri Spa limited liability offers a variety of spa treatments for use by members and guests solely at their own risk. I understand and acknowledge that the Spa makes no claims as to the safety, results or the appropriateness of any program, activity and/or treatment for any particular individual. Furthermore, I understand that the Spa reserves the right to exclude any person from utilizing the Spa facilities and/or participating in any activity or treatment at the Spa for any reason whatsoever.

2. I further acknowledge and agree that use of Spa facilities, participation in Spa programs and Spa treatments may involve a high degree of risk and at times may be hazardous to my health. I expressly agree to assume all risk associated therewith and agree to forever waive any and all claims and legal rights which I may have whatsoever, to the extent permitted by law, in connection with my use of the Spa facilities or my participation in any Spa treatment or program.

3. I understand that before participating in any exercise and/or a health related program or any Spa treatment that I should consult my physician and in the event my health condition changes while I am using the Spa facilities/treatments, I agree to consult with my physician prior to resuming any and all activities/treatments at the Spa. I understand and agree that all suggestions and/or instruction made by Spa staff concerning exercise, nutrition or any Spa treatment are neither diagnostic nor prescriptive and that I should verify the same with my physician and I will evaluate such instructions and/or suggestions independently. Notwithstanding the foregoing, I warrant and represent that I am in good health and that I am able to use the Spa facilities and participate in Spa treatments/programs, without limitation.

4. In consideration of using the Spa facilities and/or taking part in Spa treatments/programs, I agree, to the fullest extent permitted by law, to forever release, indemnify, defend and hold harmless the Spa, its subsidiaries and affiliates, their respective against, officers, directors, owners, contractors and employees (collectively the ?Released Parties?) from and all claims and causes of action which I (or the below-mentioned minor) might otherwise have or be entitled to assert as a result of or related to any physical injury or otherwise, including without limitation death or property damage or loss sustained in connection with my use (or the below-mentioned minor's use) of the Spa facilities or participation in any Spa program or treatment, including, without limitation, claims and causes of action based on negligence, breach of warranty or breach of contract. I also agree to indemnify, defend and hold harmless the Released Parties from any and all claims brought by third parties arising out of my (or the below-mentioned minor?s) acts, errors or omissions.

5. I hereby authorize Spa personnel to call for medical assistance for me or the below-mentioned minor and to transport the same to a medical facility or hospital in the event of an emergency. I further agree to be responsible for all costs and expenses associated with any such medical care and/or related transport and I hereby indemnify and hold harmless the Released Parties of and from any such costs.

6. I agree to abide by all rules and regulations as may be established from time to time by the Spa.

7. If I am executing this Release of Liability and Waiver of Rights on behalf of a minor (at least 13 years of age), I warrant and represent that I am the minor's parent or legal guardian.

8. This Agreement shall be binding on my (or the below-mentioned minor's) estate, heirs, administrators and assigns.

I have read and agree to the above liability waiver.

By submitting this form I confirm that all information is true.

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Payment disclaimer
I understand that a credit card is needed for booking but an alternate method of payment can be used at the appointment. If the appointment is cancelled with less than 48 hours advance notice, a 50% fee will be charged.