• Which Service are you scheduling? (You can click on multiple services)

  • Client Intake & Consent Form

  • Birthdate*
     / /
  •  -
  • 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.)
  • Preferred Method of Contact:

  • 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?
  • Are you ok with Essential Oils being used during your session?

  • Do you have any sensitivities to scents or allergies to ingredients?
  • Do you have any sensitivities to heat?
  • Have you suffered any recent accidents/injuries, undergone surgeries, or any other health concerns?

  • 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?

  • How do you spend your leisure time primarily?

  • 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?
  • Do you or anyone in your maternal or paternal family have red hair?
  • Sunburn History: Have you experienced a sunburn?
  • If so, where and how many times on that area?
  • Tanning Bed History: Do you use a tanning bed?

  • 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.
  • Are you on a "fat-free" diet?

  • Are you diabetic?

  • If yes, is your diabetes controlled by diet?

  • If yes, is your diabetes controlled by medication?

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

  • Do you drink the following?

  • How frequently?
  • How many cups of water do you drink a day?
  • Any weight changes that were not planned? Gain or Loss of 10 lbs within a 12 week time frame.
  • 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?

  • Any Medical Illnesses?

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

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

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

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

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

  • 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?

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

  • Do you have an impaired Lymphatic System?

  • Does your skin mark or bruise easily?

  • Have you been diagnosed with Hepatitis?

  • Do you have any other Autoimmune Disorders, such as Herpes, HIV/AIDs, etc?

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

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

  • 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?

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

  • Do you have Lupus?

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

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

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

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

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

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

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

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

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

  • 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)

  • 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)

  • 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?

  • 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?

  • 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?

  • Have you been diagnosed with Polycystic Ovaries?

  • Have you been diagnosed with Endometriosis?

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

  • Have you been diagnosed with Osteoporosis?

  • How well do you sleep?

  • 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?

  • 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?

  • Are you a smoker?

  • Cosmetic and Clinical History

  • What are the skincare brands that you've used in the past.
  • What skincare services have you received in the past?

  • 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?
  • Are you currently under any medication that can affect the skin?
  • 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?
  • Are you currently taking any Antibiotics?
  • 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?

  • Terms of Service

  • Should be Empty: