FACIALS - CLIENT INTAKE AND CONSULTATION FORM

Full Name:*

DOB*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

E-mail Address:*

example@example.com

Emergency Contact Name:*

Emergency Contact Phone Number: *

Area CodePhone Number

Skin goals and concerns:*

Your skin type*

What skincare products are you currently using? *

What makeup products are you currently using? *

Does your job and/or lifestyle require that you work/play outdoors?*

YESNO

If yes, how much time outdoors?*

Do you wax your facial skin on a regular basis?*

YESNO

If yes, when was the last time?

Have you ever had Facials, Chemical Peels, Microdermabrasion, or any Resurfacing Treatments?*

YESNO

Are you using Retin-A?*

YESNO

Are you using Benzoyl Peroxide?*

YESNO

Do you have any allergies or sensitivities? *

Have you ever experienced a reaction to any of the following? *

	YES	NO
COSMETICS
MEDICINE
IODINE (SHELLFISH)
LATEX
POLLEN
FOOD/FRUIT
ANIMALS
FRAGRANCE
ALPHA HYDROXY ACIDS
SUNSCREENS

Do you have any of the below health issues? *

	YES	NO
CANCER
CIRCULATORY ISSUES
ARTHRITIS
HORMONAL IMBALANCE
DIABETES
LACTATING
PSORIASIS
COLD SORES
CHEMOTHERAPY
HIGH BLOOD PRESSURE
HYSTERECTOMY
THYROID
PREGNANT
PLANNING TO BECOME PREGNANT
RECENT SURGERIES
ECZEMA

Do you take any medications?*

Accutane?*

YESNO

Antibiotics?*

YESNO

Birth Control?*

YESNO

Photographs: I give permission for photographs to be used by Viso Bello Spa for educational plus promotional purposes. Complete patient confidentiality will be maintained at all times. Please initial if accepted

Initial here

Name*

First NameLast Name

Signature*

Date*

Date

Translator's Name

First NameLast Name

Translator's Signature

Date

Please read, sign, and return:

CANCELLATION POLICY

Your spa treatments are reserved especially for you. We value your business and ask that you respect the spa's scheduling policies. Should you need to cancel or reschedule, Please notify us at least 24 hours in advance. Any cancellations with less than 24 hours notice are subject to a cancellation fee amounting to 50% of the cost of the scheduled service.

Clients who miss their appointments or arrive 15 minutes or more late to their appointment without giving any prior notice will be charged in full to the credit card on file for the scheduled service. We recognize the time of our clients and staff is valuable and have implemented this policy for this reason. When you schedule your appointment with us you are agreeing to these policies.

At Viso Bello Spa we understand that life can sometimes prohibit our clients from attending a scheduled appointment. However, due to our high volume of appointment requests, we ask that clients who find themselves repeatedly needing to reschedule consider contacting us for same day availability. We sincerely appreciate your understanding.

SPA ETIQUETTE

We strive to maintain a relaxing and professional atmosphere at all times. With this goal in mind please review the following:

Children: To ensure the safety of your children, and the serene environment for our clients, please make other arrangements for your children during your appointment. Children are not permitted in the lobby or treatment areas unless they are receiving a service. If you arrive to your appointment with children, you will be asked to reschedule and you will be charged for a missed appointment.

Cell Phones/ Devices: Please turn off your cell phone upon entering the lobby so as not to disturb other guests. If you must take a call, please do so outside.

Pets: No pets are allowed in our lobby or treatment rooms unless they are designated service animals.

Inappropriate Behavior: We reserve the right to refuse or terminate any appointment for inappropriate behavior. If an appointment is terminated due to lewd or otherwise offensive behavior, the full amount of the scheduled service will be charged. If an appointment is terminated for these reasons we reserve the right to refuse future appointments as well.

RETURN POLICY:

All sales are final, no returns or exchanges.

Please sign to acknowledge receipt of our policies:*