New Client Intake Form

Client Intake Form

Skin Analysis
Personal Information

All personal and medical information will be kept strictly confidential.
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*

YearMonthDay
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Occupation:
How did you hear about Savasana Beauty Bar?*
If Referral, please list name:
Let's talk about your skin
Have you ever had a facial treatment before?*

YesNo
If yes, when and what type of treatment?
What are your skin concerns?
check which apply:*

Dry skinOily skinWrinklesFine linesHyperpigmentationRosaceaAcneEczemaRednessSun spotsUneven skin toneFlaky skinWhiteheadsBlackheadsScarringMelasmaOther
Additional Information:
Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

Yes, within the last monthYes, within the last 2-3 monthsNoNot sure
If yes, which one and when?
What Skin Care Products do you currently use, if any?

***If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser(s):
Exfoliant(s):
Toner(s):
Moisturizer(s) (AM/PM):
Sunscreen(s):
Eye cream(s):
Serum(s):
Face mask(s)
Oil(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?*

YesNoYes, but not within the last 30 daysYes, but not within the last 6 monthsNot sure
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysisLaserDepilatory CreamShavingNone
If checked, please note the date:
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Let's talk about your health
Have you experienced any of these health conditions in the past or present?*

Hormone imbalanceCancerSystemic DiseaseHeart problemsArthritisAuto-immune disorderAsthmaEpilepsySeizure disorderFever BlistersHerpesFrequent cold soresHIVAIDSLupusDepressionAnxietyHepatitisHeadachesMigrainesN/A
If you checked yes to any of these, please provide further information:
Do you:*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsN/A
Do you take any of the following dietary / health supplements?*

MultivitaminIronVitamin CVitamin DD3ZincOmega 3Fish oilB ComplexB12GarlicCalciumFolic acidMelatoninCoenzymeQ10BiotinOtherNone
If other, please list:
Have you ever had an allergic reaction to any of the following?*

AspirinTree nutsLatexDairyFruitsVegetablesShellfishIodineFragrancesEssential oilsOtherNone
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used:
Are you a smoker?*

YesNo
How many glasses of water do you drink a day?
How many caffeinated drinks do you drink a day?
Do you experience claustrophobia under the facial steam or warm towels*

YesNo
Female Clients only
Are you taking birth control?

YesNo
If yes, what kind?
Are you pregnant or trying to become pregnant?

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues?

YesNoN/A
If yes, please specify:
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify:
Male Clients Only
What is your current shaving system?

RazorWet ShaveElectricN/AOther
Do you experience irritation from shaving?

YesNo
Photo Consent and Release
I give Savasana Beauty Bar permission to take photos of my treatment and/or treated areas to be used for the purpose of monitoring my progress.

YesNo
I give Savasana Beauty Bar permission for my photos to be used for education.

YesNo
I give Savasana Beauty Bar permission for my photos to be used for advertising on social media.

YesNo
I give Savasana Beauty Bar permission for my photos to be used on the Savasana Beauty Bar website.

YesNo
Post Facial Care
- Refrain from exfoliating your skin 48-72 hours before your appointment, especially with products containing retinol/retinoids or BHA’s. Exfoliation can make the skin more sensitive and increase the risk of complications.
- Avoid sun exposure and tanning beds before your appointment, as they can increase skin sensitivity.
- Stay clear of laser treatments and waxing procedures for the five to seven days PRE AND POST treatment to prevent any complications.
Post Facial Care
- Minimize sun exposure to protect your skin: Sun exposure can cause damage and hinder the healing process.
- Always apply and reapply a broad spectrum SPF diligently: SPF shields your skin from harmful UV rays and maintains treatment results.
- Refrain from engaging in vigorous exercise or swimming for the next 48 hours: Excessive activity can increase the risk of inflammation and irritation.
- Avoid any skin exfoliation procedures for five to seven days PRE AND POST facial: Avoid using your AHA's/BHA's and retinols/retinoids.
- Maintain a consistent at-home skincare routine for the best possible outcomes: Regular care complements and extends the benefits of your treatment.
- Keep your skin well-hydrated and regularly moisturized: Hydration is essential for skin health and helps maintain your results.
- For optimal results, consider going makeup-free for one to two days following your treatment: This allows your skin to breathe and recover, enhancing the treatment's effectiveness.
I have read the pre and post care instructions and agree to adhere to them.
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. In the event of cancellations received less than 24 hours prior to appointment, a cancellation fee equal to 100% of the reserved service booking will incur.
I understand the reservation and cancellation policies at Savasana Beauty Bar and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.
Signature*

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