Allied Health Care - Day Spa / Massage Terapy Supplement Allied Health Care – Day Spa : Massage Terapy Supplement APP PDF Download Allied Health Care - Day Spa / Massage Therapy Supplement 1) Name of Applicant: Prefix First Last Suffix 2) Please list all services the applicant currently provides or intends to provide over the next 12 months:*Type of ServiceAnnual Number of ProceduresName and Job Title of Person Performing Procedure (Please click the plus button to each additional service)3) If any of the applicant's services involve the following, please note in the space provided the number of procedures over the past 12 months:Ablative laser resurfacingDermal fillersFraxel/Laser removal of wrinkles, scars, age spots/tattoo removalInsertion of permanent makeup/pigment in or under the skinLaser skin rejuvenationOther surgical proceduresThermageBotox/Restylane/Filler injectionsEar/Body piercingMedical peelsOxygen barDental spa servicesElectrolysisInfared body wrapsLaser and intense pulsed light proceduresMedical spa servicesPhoto-facials4) Does the applicant provide chemical peel services?* Yes No If "Yes"Are all chemical peels performed by a licensed Aesthetician? Yes No Percentages of all chemical peel services:Overall spa services consisting of chemical peels?*10%20%30%40%50%60%70%80%90%100%Chemical peels that are "light" (superficial, us Aha's/salicylic acids)*10%20%30%40%50%60%70%80%90%100%Chemical peels that are "medium" (TCA's) using solution strength (under 20%):*Less than 10%10%20%Chemical peels that are "medium" (TCA's) using solution strength (over 20%):*30%40%50%60%70%80%90%100%Chemical peels that are "deep" (Phenol)*10%20%30%40%50%60%70%80%90%100%5) Percentage of services provided to minors:*10%20%30%40%50%60%70%80%90%100%6) Percentage of services involving pregnancy massage:*10%20%30%40%50%60%70%80%90%100%6a) Percentage of pregnancy massage in 1st or 3rd trimesters:*10%20%30%40%50%60%70%80%90%100%7) Does the applicant provide tanning services? Yes No If "Yes", what percent of overall spa services involve tanning?10%20%30%40%50%60%70%80%90%100%Does the applicant have waterless massage machine(s)?* Yes No Does the applicant have saltwater flotation chamber(s)?* Yes No This supplemental application is incorporated into and is deemed a part of the other application(s) submitted in connection with the requested insurance. any and all notices and representations included in such other application(s) are incorporated by reference in this supplemental application as though fully set forth herein.Name of Applicant:* (Please type full name in space provided)Title:* Applicant's Signature:*(Principal, Partner or Officer) (Please use your mouse on a PC or Mac, or your finger or stylus on a tablet or smartphone to sign your name.).Date:* MM slash DD slash YYYY Producer Name:* Retail Agency Name:* Agent's Signature:*(Required in New Hampshire)EmailThis field is for validation purposes and should be left unchanged.
