Client Intake Form
Name:
First Name
Last Name
Age:
Date of Birth:
-
Month
-
Day
Year
Date
Gender
Please Select
Female
Male
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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What is your skin care goal?
What are your skin care challenges?
Wrinkles/Fine Lines
Hyperpigmentation/Sun Damage
Acne/Acne Scarring
Redness/Rosacea
Sensitivity
Aging
Melasma
Other
Have you had facial treatments before?
Yes
No
Please list types of treatments and when:
If you have received any hair removal services in the last 30 days (including Nare) please list:
Please list any current prescribed skin treatments/medications/topical products:
Have you received chemical peels, laser treatments, microdermabrasion, or other skin resurfacing treatments?
yes, within 30 days
yes, within the last 3 months
no
Please mark all that apply to you:
Pacemaker
Cancer
Epilepsy
Heart Conditions
Recent Facial Surgery
Recent Facial Injection
Metal Pins/Plates
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Submit
I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.
I understand that spa therapies/facials are not a replacement for medical treatment and by signing below do give full permission to Naomi Nalzaro to administer appropriate services as agreed upon by both parties.
No Personal or medical information will be share with any third party organization.
Signature of spa guest:
(If under the age of 18) Name of parent:
First Name
Last Name
(if under the age of 18) Signature of parent:
Submit
Should be Empty: