Spa Days Are The Best Days WELCOME TO LIFESPA! "*" indicates required fields Name* First Last Phone*Email* Preferred Method of Communication* Phone Email Texting is available to members that opt in on myLT or LT app. Download the app if you’d prefer to receive updates that way! Personalize Your ExperienceTo make the most of your time with us, please let me know how to enhance your upcoming salon experience. Engagement: What’s your ideal in-salon vibe?* I need Zen Let's Talk Ask me when I check-in Select a Complimentary BeveragePower up your water with nutrients & antioxidants that improve hydration and support overall health and wellness with zero calories or sugar.HiddenComplimentary BeverageTemperature* Hot Cold Flavors* Cranberry & Elderberry Coconut Plain Select a Complimentary Refresh Towel This experience allows aromatherapy to change your mood quickly by stimulating your central nervous system through breath. Essential oils in the towel applied to the skin promote health and wellness, improving the body, mind, and spirit.HiddenComplimentary Refresh TowelTemperature* Hot Cold Essential Oils* Eucalyptus Lemon Lavender Let's Talk About YouSave time by providing your information pre-appointment so our team can ensure a personalized experience for you.I have a*Check all that apply. Skincare/Facial Appointment Massage/Body Appointment Our team uses your unique information to create a safe and nourishing experience. When was the last time you filled out an assessment?* Within the last two months. It’s been longer than two months. Let’s do it now. It’s been longer than two months. I’ll do it when I check in. Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name Emergency Contact PhoneSkin Intake FormTell us about yourself! Our team of professionals considers your needs, preferences and medical history when creating your individualized treatment.Your genetic background affects your skin and its response to treatments. Please specify your ethnic origin:Select...African AmericanAsianCaucasianHispanicMediterraneanNative AmericanMixed RaceOtherI choose not to answerIf 'Other', please specify: Areas of concern for me:Areas of concern for me: Acne Back acne Crow's-feet Dryness/dehydration Dark circles under eyes Deep lines around mouth Excess fat Excessive sweating Fine lines and wrinkles Frown lines Freckles/brown spots Lash length/thickness Large pores Redness/rosacea Loss of elasticity Sensitive skin Spider veins Texture of skin Thin or uneven lips Uneven skin tone Unwanted hair Melasma Scars PLEASE INDICATE AREAS OF FOCUS:Check all the areas of focus or concern you’d like to discuss with your technician at your appointment. ForeheadFOREHEAD Focus Concern Any Details? EyesEYES Focus Concern Any Details? Under EyesUNDER EYES Focus Concern Any Details? T-ZoneT-ZONE Focus Concern Any Details? CheeksCHEEKS Focus Concern Any Details? LipsLIPS Focus Concern Any Details? ChinCHIN Focus Concern Any Details? Décolleté DECOLLETE Focus Concern Any Details? ShouldersSHOULDERS Focus Concern Any Details? HandsHANDS Focus Concern Any Details? Reset FieldsPlease Explain:If the answer to any of the following is yes, please provide further details to your Esthetic Care Provider.Do you have an active skin disease or infection?* Yes No If yes, please describe* Have you had a chemical peel or facial within the last week?* Yes No If yes, when?* Have you had any permanent cosmetic tattooing?* Yes No If yes, when and what areas?* Have you received any Botox or dermal filler injections within the last two weeks?* Yes No If yes, when?* Have you received any facial laser treatments within the last 4 to 6 weeks?* Yes No If yes, when?* Do you have any metal or synthetic implants?* Yes No If yes, describe* Are you currently using tanning creams?* Yes No If yes, what products?* Have you been exposed to the sun or used tanning beds within the last 4 weeks?* Yes No If yes, approximate date of last exposure* Do you wear contact lenses?* Yes No Do you consume alcohol on a daily basis?* Yes No If so, how much?* Are you currently being treated for a medical condition?* Yes No If yes, describe* How many 8-oz. Glasses of water do you consume daily?*1-23-56-8Select all medications you take, including prescription and over-the-counter drugs (aspirin, anti-inflammatory), vitamins, herbs, supplements Retin-A/Retinols Accutane Vitamin C Products Alpha Hydroxy or Glycolic Acids Beta Hydroxy or Salicylic Acids Topical or Oral Antibiotics Other If Other, please list: List any known allergiesMedications (please list) Skin care products (please list) Other Latex Lidocaine Shellfish FemalesAre you currently pregnant or nursing?* Yes No Are you planning to become pregnant within the next year?* Yes No Please indicate the name and brand of your current skin care products This includes cleanser, toner, treatment/correctives, day moisturizers, night moisturizers, masques, sunscreens, eye cream, topical Rx or others. Please indicate the name and brand of your current skin care productsSignatureI understand that if I have a specific medical condition or specific symptoms, facial/bodywork may be contraindicated. A referral from my primary care provider may be requested prior to service being provided. I understand that the facial/bodywork I receive is provided for the basic purpose of relaxation and skin care initiatives. If I experience any pain or discomfort during my session(s), I will immediately inform the practitioner. I further understand that the facial/bodywork is not a medical examination, diagnosis or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical illness. Because facial/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I will keep the practitioner updated as to any changes in my medical profile. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of that session. I understand and agree that the Service(s) which I have purchased with this Agreement involve the risk of injury and I elect to participate in the Service(s) voluntarily in spite of the risk, and agree to indemnify and hold harmless Life Time Fitness, Inc., and all its subsidiaries, affiliates, directors, owners, employees, representatives, volunteers and agents. I further understand and agree that the terms of my General Terms Agreement and Member Usage Agreement continue to apply, including the assumption of risk, waiver of liability and indemnification provisions contained therein.I am over the age of the age of 18* Yes No Signature: Type Name* Date* MM slash DD slash YYYY I, the undersigned parent or legal guardian of the participant, hereby execute the foregoing for and on behalf of the participant and agree to bind myself, the participant and any heirs, next of kin, assigns or personal representatives to such terms. I represent that I have full legal authority to act for and on behalf of the participant, and I agree to indemnify and hold harmless Life Time Fitness, Inc., and its subsidiaries for any expenses, claims or liabilities that may arise as a result of any insufficiency of my full legal authority to execute the foregoing. Parent or Guardian Signature: Type Name* Date* MM slash DD slash YYYY Massage Intake FormTell us about yourself! Our team of professionals considers your needs, preferences and medical history when creating your individualized appointment. How many 8-oz. Glasses of water do you consume daily?*1-23-56-8Your day includes 60% or more of the followingSittingStandingRepetitive TasksPrograms you participate in or are interested in*(Select all that apply) Cycle Run Swim Triathlon Body Sculpt Yoga Pilates Golf Racquet Sports None of the above Other If Other, please specify Are you interested in learning more about the Detoxifying Back Treatment?* Yes No Your NeedsTell us about the areas you want us to focus or avoid, give as much detail as you’d like, or we can talk through together!HEADHEAD Focus Avoid Any Details? TEMPLESTEMPLES Focus Avoid Any Details? NECKNECK Focus Avoid Any Details? SHOULDERSSHOULDERS Focus Avoid Any Details? ARMSARMS Focus Avoid Any Details? UPPER BACKUPPER BACK Focus Avoid Any Details? MID-BACKMID-BACK Focus Avoid Any Details? LOWER BACKLOWER BACK Focus Avoid Any Details? HIPSLOWER BACK Focus Avoid Any Details? LEGSLEGS Focus Avoid Any Details? FEETFEET Focus Avoid Any Details? Medical Concerns | Family Medical HistoryMedical Concerns | Family Medical History Acne AIDS/HIV Anemia Arteriosclerosis Arthritis Asthma Athlete’s foot Back pain Blood clots Broken bone(s) Burns/sunburn Cancer/Remission Cellulite Chronic bronchitis Circulatory problems Constipation Cuts or sores Diabetes Diarrhea Dizziness Dryness/dehydration Epilepsy Emphysema Heart attack Headaches Hernia Herpes High blood pressure High cholesterol Joint pain Kidney disease Liver disorders Muscle tension Nervousness Paralysis/numbness Plates/screws Pregnant Rash/shingles Sinusitis Sleeping disorder Stents/shunts Spinal problems Stress Stroke Thrombosis Ulcers Varicose veins Anything else we should know or want to share with us?SignatureI understand that if I have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from my primary care provider may be required prior to service being provided. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session(s), I will immediately inform the practitioner. I further understand that massage/bodywork is not a medical examination, diagnosis or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical illness. Because massage/bodywork should not be performed under certain medical conditions. I affirm that I have stated all my known medical conditions and answered all questions honestly. I will keep the practitioner updated as to any changes in my medical profile. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of that session. I understand that the Service(s) which I have purchased with this Agreement involve the risk of injury and I elect to participate in the Service(s) voluntary in spite of the risk, and agree to indemnify and hold harness Life Time, Inc., and its subsidiaries, affiliates, directors, owners, employees, representatives, volunteers and agents. I further understand and agree that the terms of my General Terms Agreement and Member Usage Agreement continue to apply, including the assumption of risk, waiver of liability and indemnification provisions contained therein. LifeSpa reserves the right to refuse service to anyone at anytime. LifeSpa technicians will not massage sensitive or private areas such as female breasts, groin areas and buttocks. While in massage room all patrons must have underpants on or remain covered at all times with draping. I understand I have the right to end the session at anytime.I am over the age of the age of 18* Yes No Signature: Type Name* Date* MM slash DD slash YYYY I, the undersigned parent or legal guardian of the participant, hereby execute the foregoing for and on behalf of the participant and agree to bind myself, the participant and any heirs, next of kin, assigns or personal representatives to such terms. I represent that I have full legal authority to act for and on behalf of the participant, and I agree to indemnify and hold harmless Life Time Fitness, Inc., and its subsidiaries for any expenses, claims or liabilities that may arise as a result of any insufficiency of my full legal authority to execute the foregoing. Parent or Guardian Signature: Type Name* Date* MM slash DD slash YYYY UPGRADE OPTIONSWe offer a range of enhancements to add to your spa experience. Check all services of interest to discuss further with your technician during your consultation.MINI SERVICES Patchology Eye Treatment $10 Patchology Lip Masque Treatment $10 Patchology Face Masque Treatment $15 Patchology Softening Foot & Heel Masque $15 Patchology Acne Spot Treatment $5 Patchology Hand & Cuticle Masque $15 Meditation Space (30 min. Post-Treatment Alone Time) $30 Facial Pressure Point (15 min. Sinus Massage) $15 Scalp Relax (15 min. Head Massage) $15 Hand/Foot Relax (15 min. Massage) $15 WELLNESS SERVICES Stone Surfacing Treatment (15 min. Himalayan Salt Cellulite Treatment) $40 Sport Flow (15 min. Kinesiology Tape Therapy) $31 Back Facial (15 min. Back Detox Treatment) $25 Surfacing Treatment (15 min. Dry Brushing Treatment) $35 Stone Detox Treatment (15 min. Himalayan Salt Stone Therapy) $25 AESTHETIC SERVICES Bold Brows (30 min. Brow Tint) $25 Brow Shaping (15 min. Brow Wax) $20 Lash Detail (30 min. Lash Tint) $31 Let’s Talk Lashes (15 min. Consultation) Complimentary Rejuvenating Treatment (30 min. Skin Peel) $51 Smoothing Treatment (15 min. LED Light Therapy) $30 HiddenWhere are you receiving your service?LocationMN – Edina SouthdaleMN – Chanhassen
