Client Intake Form

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

How did you hear about us?

Have you ever had a facial treatment before?

If yes, when?

Which of the following best describes your skin type?

Type I-creamy complexion; always burns easily and never tansType II-light complexion; always burns and tans slightlyType III-light/matte complexion; burns moderately and tans graduallyType IV-matte complexion; seldom burns and always tans wellType V-brown complexion; rarely burns and deep tanType VI-black complexion; never burns and deeply pigmented

Do you wear contact lenses?

Do you smoke?

Are you pregnant?

Are you taking birth control pills?

Are you currently taking medications? If so, please list.

Have you ever had chemical peels, laser, or Microdermabrasion?

Have you had any of these services within the last month?

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/Vitamin A derivative products?

Have you used any of these products within the last 3 months?

Please last any acne medications you have used and the dates from which they were used.

Have you used Accutane within 12 months?

Please list all skin care products you are currently using as well as the brand.

Have you been under a physicians care for any current skin condition or other problems?

What areas of concern do you have regarding your skin?

Please list any known allergies. If none please write “none”

Aromatherapy preference

What SPF do you use on your face? How often/when?

Have you experienced Botox, Restylane, or Collagen injections?

Please check if you are affected by or have any of the following

Please explain above problems or list any other significant issues

LATE ARRIVALS
It is best to arrive 10 minutes before your scheduled start time, especially if you are a new client to fill out the facial questionnaire and other forms. If you will be more than 15 minutes late to your appointment for the courtesy of clients after you we may have to reschedule. In order to get the most of your treatment please be on time!

CANCELLATIONS/RESCHEDULING
Your appointment is very important to me. It is reserved especially for you. I understand that sometimes schedule adjustments are necessary.
Therefore, I respectfully request at least 24 hours notice prior to your scheduled appointment time for cancellations or rescheduling of appointments.
ANY APPOINTMENTS CANCELLED/CHANGED WITHOUT 6 HOURS NOTICE OR “NO SHOWS” WILL RESULT IN CHARGE OF $40
When you miss an appointment, I not only lose your business, but also the potential business of other clients who could have scheduled an appointment for the same time.

Please remember that it is your responsibility to remember your appointment dates and times in order to prevent any missed appointments which result in a cancellation fee. Not receiving an electronic notification of your appointments from us is not sufficient reason to miss an appointment if the original confirmation notification was received timely. Please note all booked appointments must be accepted and confirmed before the appointment is made. You will receive a text message stating this.
It is mutually understood that if a cancellation is due to circumstances beyond any of our control, such as power outage, unfortunate incidence, or weather that requires you or us to have to cancel or be closed during regular business hours, I will reschedule your existing appointment and no discount or rescheduling fee will apply.

PAYMENT POLICY
A valid credit card number is required at the time of booking. Full payment is due at time of service. I accept cash, Cash app, Vemno, Zelle and credit cards with a 4% fee. I do not accept personal checks.

MEDICAL CONDITIONS
Please advise me at the time of booking of any health conditions, allergies, injuries, recent surgeries, pregnancy or special needs which may affect your services.
Some treatments are not recommended for guests who have certain conditions. For your safety we require a doctor’s clearance before beginning treatment, particularly in the face of the following conditions:
• Cancer
• Cardiovascular conditions, including high or low blood pressure
• Swollen or painful lymph nodes
• Undiagnosed skin rash or thrombosis
• New injury of any kind
• Open sores
• Arthritis (osteo- or rheumatoid)
• Diabetes
• Blood Disorder and Disease
Please note that individuals who have received Botox or Dermal fillers (any injectables), chemical peels, micro-needling, micro-blading, permanent makeup/tattoo, cosmetic treatments with laser or ultrasound, Must wait at least 2 weeks before any facial treatment can be performed.
Individuals prescribed Accutane ( Isotretinoin Therapy) must wait 6-12 months after completion of the prescription before most facial treatments can be performed.

PRICES AND SERVICES
Prices and services are subject to change without notice. I will do my best to keep clients up to date on any changes that may occur but encourage all clients to inquire about pricing and available services when booking your appointment.

REFUNDS
Unfortunately, skin care products, services and gift cards/certificates are non-refundable.

PERSONAL BELONGINGS
Please leave all jewelry and valuable items at home. NOVO Spa Studio is not responsible for any lost or misplaced items.

CHILDREN & VISITORS ACCOMPANYING THE CLIENT
Due to our limited seating and small space the facilities are reserved for clients only. I am unable to accommodate visitors or children accompanying you during your service.

AGE REQUIREMENTS
All services provided on minors must be done with a parent or legal guardian present.
All guests under the age of 18 must bring a signed consent form.

Please list any additional comments and/or concerns.

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