初来店日

DateYear MonthDay

氏名 Name
生年月日 Date of birth Year

MonthDay

住所 Address
TEL Telephone number
DM は自宅 Direct Mail to home

OKNO

携帯 Cellphone number
勤務先 Place of employment
社名 Corporate name
TEL Company Telephone number
備考 Noteアンケート Questionnaire
Have you ever been diagnosed by a doctor with high blood pressure?

YESNO

Are you presently or in the past been treated for an illness?

YESNO

Do you ever become overtired easily?

YESNO

Are you always tired in the morning when you wake up?

YESNO

Do you have a nervous disorder or nervousness?

YESNO

Is there anybody in your family who has a nervous disorder?

YESNO

Do you get irritated easily?

YESNO

Are your hands and feet cold even in summer?

YES

NO

Do you have menstrual irregularity?

YESNO

Are you presently taking any medication?

YES

NO

If YES, please describe the illness? ()Have you ever been diagnosed with one of the following in a physical examination?
1. Heart disease

2. Anemia

Are you presently or in the past been treated by a dermatologist?

YESNO

YESNO

Do you have any allergic symptoms?

YES

NO

Do your bruises or scars remain for a long time?

YESNO

Are you claustrophobic?

YESNO

Do you have any artificial teeth?

YESNO

What kind of symptoms? ()Do you wear contact lenses?
Do you experience constipation?
1. Always

Sometimes

3. NO

Reason of visiting?
1. Referral from a friend (Would you please provide the name? _______________)
2. Leaflets
3. Internet
Would you like to hear about the treatment or any advice?
1. Yes, during the treatment.

2. No, I would prefer to relax.

3. Yes, after the treatment.

Thank you for your cooperation. We will do are best to make our customers happy and satisfied.

誓約書 Consent FormThank you for choosing Mary Grace Japan out of many esthetic salons.
We will only treat customers who agree to the points listed below.
Service will not be rendered under the following circumstances:•Demand for other treatments that we do not offer•Actions which lack character or inappropriate remarks; touching the therapist•Demand for sexual treatment (Note1)•Therapist feels danger due to actions or remarks which could harm the therapist•When it is judged that the customer is unsuitable for service•When the customer removes more clothing than needed for the service (Note2)•When the utterance etc, lack in character or if it is bad•Customers who are drunk•Customers who have any kind of tattoos•Customers presently seeing a doctor or currently taking any medication•Customers with heart disease•Customers with any infectious disease•Customers who have a pacemaker•Customers who have diabetes
Note 1 ) Special treatment requests not permitted.
Note 2) We kindly ask all male guests to wear underwear during all treatments.
Customers who correspond with the above points will be prohibited from using the salon.

treatment if thetherapist judges anyone as corresponding with the above points, the session will be considered cancelled,
treatment will be stopped immediately and the customer will be requested to leave the premises. In this case,the appropriate fee will be charged with the cancellation fee and a refund will not be made.
※ If we feel that it is necessary, we will ask for your identification and ask you to accompany our staff to thepolice station. ※ Please follow the rules and we ask for your understanding and cooperation.
※Representation and Covenants regarding Criminal or Antisocial organizations.

(Personal belongings) We cannot take responsibility for any missing items.
I (print name)____________________ understand that I will be treated by a Mary Grace therapist and will follow
all rules and will take responsibility for my own actions.
I have no objection with anything above.

YEAR

MONTH

DAYSignatureExclusion of Anti Social Forces
1. "Anti Social Forces" means:(1) an organized crime group, a member of an organized crime group, a related company or association of anorganized crime group, and any other equivalent person of above; or(2) a person who themselves or through the use of third parties conducts a demand with violence, an
unreasonable demand beyond its legal entitlement, use of intimidating words or actions, damages the credit orobstructs the business of the other party by spreading false rumors or by the use of fraudulent, or any otherequivalent actions of above.
2. Each party represents and warrants that is not a person who has fallen and shall not fall under any of thefollowings:(1) the Anti Social Forces;(2) a person having such relationship with the Anti Social Forces that shows the Anti Social Forces' substantial
involvement in the person's management;(3) a person having such relationship with the Anti Social Forces that shows reliance on the Anti Social Forces;(4) a person who cooperate and is not involved with the maintenance or operation of any Anti social Forces byproviding funding to any Anti Social Forces or any similar act; or(5) a person who is engaged in socially condemnable relationship with the Anti Social Forces.
2. Each party shall be entitled to terminate this Agreement and request for the damages without any notice
and any and all obligations of the party owed to the other party shall become due and payable and the otherparty shall immediately repay such obligations, if the other party breached the representations andwarranties in the preceding clause.

memo