Castillo Massage and Skincare Studio: Client Intake & Consent Form

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MassageSkin CorrectionWaxing
Client Intake & Consent Form
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date (Use this format: mm/dd/yyyy)
Email*
example@example.com
Phone Number*

Area CodePhone Number
Do you want to be added to our email list for promotions/monthly specials? (We hate spam and promise to send 1 email per month MAX.)

Yes (Check your spam inbox for the initial email!)No (Don't worry, I take no offense.)
Preferred Method of Contact:

Phone CallText MessageEmailOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
If referred by someone, type in their name. (We give referral rewards)
Overview

Please take the time to carefully read and answer the following questions to the best of your abilities. This will ensure your safety and allow your therapist/esthetician to give you the best service possible. If you have any medical conditions, experiencing any symptoms, or have a medical history, skincare services may be contraindicated.

All services provided by Castillo Massage and Skincare Studio and its employees, are professional in nature. Castillo Massage and Skincare Studio upholds the highest professional standards and reserves client modesty at all times. Solicitation/Request for services of the sexual nature will not be tolerated and will result in a ban from future services and/or up to legal action.

Be kind and respectful.
Massage Services
Have you ever received a professional massage session?

YesNo
What did you enjoy from it?
What did you not enjoy from it?
What brings you to the studio? What are your goals?
Are you ok with Essential Oils being used during your session?

YesNoOther
Do you have any sensitivities to scents or allergies to ingredients?

YesNo
What type of pressure do you prefer?
This is a subjective questions, but it gives a baseline to work with.
Do you have any sensitivities to heat?

YesNo
Have you suffered any recent accidents/injuries, undergone surgeries, or any other health concerns?

YesNo
If Yes, explain.
Skin Correction

This intake form is imperative to correcting your skin concerns. Please take your time to answer all the following questions to the best of your ability. Your answers will shape your skin treatment experience, and any unanswered questions will be asked during your skin consultation.
What is your Work Environment like?

Easy GoingStill and SedentaryStressfulHazardousShiftworkLaborious and PhysicalOther
How do you spend your leisure time primarily?

IndoorsOutdoorsSportsNight LifeOther
Sun Exposure and Genetic History

The following questions will help to ascertain your photo type and whether or not your skin is considered "high risk" for pigmentation skin conditions, skin cancer, or vascular skin conditions.
Does your skin tan?

Yes, my skin can tan or is suited for the sun.No, my skin turns red and burns.
Do you or anyone in your maternal or paternal family have red hair?

YesNoUnsure
If so, who?
(Carriers of the Red Hair Gene)
From where do your maternal and paternal grandparents originate?
Where did you live for the first 25 years of your life?
Sunburn History: Have you experienced a sunburn?

YesNo
If so, where and how many times on that area?
Tanning Bed History: Do you use a tanning bed?

YesNoOther
If so, how frequently?
(Tanning bed usage)
Nutritional Information

Our cells can only function as well as the nutrients it receives. These questions will bring insight to possible deficiencies that affect skin health.
Time of your last meal of the day:
How many meals daily, and approximately what size?
How many times per week do you get fast food or take out?
How would you describe your diet?
Are you on a "fat-free" diet?

YesNoOther
If so how long?
(Length of time on a Fat-Free Diet)
Any known Food Intolerances?
These are different from food allergies in that these are foods that don't always like you back. Digestive disorders such as wind, bloating, and similar types of discomfort occur after consumption. (Ex: Lactose Intolerant, Celiac Disease, Sulphites (wine, dried fruit, canned goods), etc)
Any known Food Allergies?
These are life-threatening reactions upon contact or consumption of certain foods. (Ex: Shellfish, Tree Nuts, Milk, Eggs, Fish, etc)
Are you diabetic?

Yes, Type 1Yes, Type 2NoOther
If yes, is your diabetes controlled by diet?

YesNoOther
If your diabetes is controlled by diet, please explain what changes you've made.
If yes, is your diabetes controlled by medication?

YesNoOther
If yes, please list the diabetes medication name, dosage, and date of first use.
Are you anemic?

YesNoOther
Do you drink the following?

AlcoholCoffeeSodaTeaOther
How frequently?

Rarely1/Day2-3/Day3-5/ Day
How many cups of water do you drink a day?

When I remember.1-23-45-67-8
Any weight changes that were not planned? Gain or Loss of 10 lbs within a 12 week time frame.

YesNo
Are you taking vitamins or any supplements? If yes, please list.
Medical History and Medication Details

Surgeries, medications, and your health history play an important role in the development of your skin's current state. They also influence the skincare treatment you receive and any modifications needed to proved the best service.
Are you able to lay flat on your back for an extended period of time without discomfort?

YesNoOther
Any Medical Illnesses?

YesNoOther
If yes, please list the medical illness, and the date it was diagnosed.
Any Medical Surgeries?

YesNoOther
If yes, please list the name of the medical surgery, and the date it was performed.
Any Cosmetic Surgeries?

YesNoOther
If yes, please list the name of the cosmetic surgery, and the date it was performed.
Any Cosmetic/Surgical Implants?

YesNoOther
If yes, please list the cosmetic/surgical implant name, and the date it was placed.
Blood Pressure Medication?

YesNoOther
If yes, please list the blood pressure medication name, dose, and how long you've been on the medication.
Cardiovascular Medication?

YesNoOther
If yes, please list the cardiovascular medication name, dose, and how long you've been on the medication
Do you have varicose veins or varicose bruising?

YesNoOther
Do you have any bleeding disorders such as hemophilia, or on blood thinning medication?

Yes, hemophilia.Yes, blood thinners.NoOther
Do you have an impaired Lymphatic System?

YesNoOther
Does your skin mark or bruise easily?

YesNoOther
Have you been diagnosed with Hepatitis?

Yes, Hepatitis AYes, Hepatitis BYes, Hepatitis CNoOther
Do you have any other Autoimmune Disorders, such as Herpes, HIV/AIDs, etc?

YesNoOther
If yes, please list the autoimmune disorder's name, diagnosis date, and medication name.
Do you have Epilepsy

YesNoOther
If yes, please list the epilepsy medication name, dose, and how long you've been on the medication.
Do you have a Thyroid Disorder?

Yes, overactive.Yes, underactive.NoOther
If yes, please list the thyroid medication name, dose, and how long you've been on the medication.
Is your skin prone to keloid scarring?

YesNoOther
Do you have Vitiligo? (Areas of lost pigmentation)

YesNoOther
Do you have Lupus?

YesNoOther
If yes, please list the Lupus medication name, dose, and how long you've been on the medication.
Do you have Rosacea?

YesNoOther
If yes, please list the Rosacea type, dose, and how long you've been on the medication.
Do you have Asthma?

YesNoOther
If yes, please list the asthma medication name, dose, and how long you've been on the medication.
Do you have Eczema?

YesNoOther
If yes, please list the eczema medication name, dose, and how long you've been on the medication.
Do you have Dermatitis?

YesNoOther
If yes, please list the dermatitis medication name, dose, and how long you've been on the medication.
Do you have Psoriasis?

YesNoOther
If yes, please list the psoriasis medication name, dose, and how long you've been on the medication.
Do you have Arthritis?

YesNoOther
If yes, please list the arthritis medication name, dose, and how long you've been on the medication.
Do you have Allergies?

YesNoOther
If yes, please list the arthritis medication name, dose, and how long you've been on the medication.
Do you carry an EpiPen?

YesNoOther
If yes, please list the allergen, medication name, dose, and how long you've been on the medication.
Are you on Anti-Depressants?

YesNoOther
If yes, please list the anti-depressant medication name, dose, and how long you've been on the medication.
Are you taking any Acne Medication? (Accutane, Aczone, Differin, Isotretinoin etc)

YesNoOther
If yes, please list the acne medication name, dosage, and how long you've been on the medication.
Are you taking any Antibiotics or Anti-Fungal Medication? (Tetracycline, Macrolide, etc)

YesNoOther
If yes, please list the antibiotic/anti-fungal medication name, dosage, and how long you've been on the medication.
Did you have a hysterectomy?

Yes, fullYes, partialNoOther
If yes, please list the if you are undergoing hormone replacement therapy, dosage, and how long you've been on the medication.
Are you menopausal?

YesNoOther
If yes, please list if you are you currently taking any menopausal medication, dosage, and how long you've been on the medication.
Do you have irregular menstruation cycles?

YesNoOther
Have you been diagnosed with Polycystic Ovaries?

YesNoOther
Have you been diagnosed with Endometriosis?

YesNoOther
Do you have superfluous hair? (Excess Body Hair)

YesNoOther
Have you been diagnosed with Osteoporosis?

YesNoOther
How well do you sleep?

Same time, regular cycle, very consistent.Inconsistent, changes every day.Insomniac, very little sleep if at allOther
If your sleep pattern is inconsistent, please list any medication or alternative therapies used, and how long you've been using these methods.
Do you suffer from chronic pain?

YesNoOther
If yes, please list any medication or alternative therapies used to manage your pain, and how long you've been using these methods.
How would you describe your stress levels?

Easy GoingMild Daily StressModerate Daily StressVery Demanding LifestyleOther
How do you manage and control your stress levels?
Are you a smoker?

YesNoOther
If yes, please list how many cigarettes you smoke a day.
Cosmetic and Clinical History
How do you currently feel about your skin?
What brings you to the studio, today?
What are the skincare brands that you've used in the past.
Why did you stop using these brands/products?
What skincare services have you received in the past?
Did these services meet your expectations?
Current Skincare Routine
Cleansers
Toners
Serums
Moisturizers/Day Creams/Night Creams
Eye Creams
SPF
Exfoliants
Masks
Makeup
Waxing Services
Have you ever received a professional wax service before?

YesNo
If Yes, how long ago?
Are you currently under any medication that can affect the skin?

YesNo
If Yes, explain.
Are you currently on any form of Vitamin A? Including but not limited to: Retin-A, Retin-A micro, Retinol, Retinyl Palmitate, Retinaldehyde, Adapalene, Isotretinoin, Tretinoin, or Tazarotene?

YesNo
Are you currently taking any Antibiotics?

YesNo
Due to the possibility of blood/body fluid exposure, this question is important. Do you have any auto immune disease such as: Lupus, HIV/AIDs, or Hepatitis?

YesNoOther
If Yes, explain.
Anything other information you would like to share with me?
Terms of Service
By accepting services provide by Castillo Massage and Skincare Studio, “I”, the client, authorize Creative Wolf Studio LLC to charge my credit/debit card for agreed upon transactions and cancellation polices. I also understand that the purpose for massage is for the relief of muscular tension and relaxation, and the purpose of skincare services is for relaxation and relief of some skincare concerns. I understand that these services will in no way be construed as a substitute for medical examination and any ailments should be brought to the attention of medical practitioner. I further agree to release Castillo Massage and Skincare Studio, its owners, employees, and affiliates from any and all claims I may have or be entitled to assert as a result of or related to any physical injury or otherwise, including without limitation death or property damage or loss sustained in connection with the facility or participation with treatments received. I also agree to hold indemnify and hold harmless the “Released Parties” from any and all claims brought by third parties arising from my, the client, acts, errors, or omissions. Do you agree to the terms of service?*

I agree to the Terms of Service
Signature*

Clear
Parent's/Guardian's Signature (if under 18)

Clear
Should be Empty:

Client Intake & Consent Form

Overview

Massage Services

Skin Correction

Sun Exposure and Genetic History

Nutritional Information

Medical History and Medication Details

Cosmetic and Clinical History

Current Skincare Routine

Waxing Services

Terms of Service