Elle Marie Spa: Skincare Facial Consent Form

Elle Marie Spa

Skin Services Intake Form
Date *

Month Day Year
Date
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
How did you hear about us?

Walked by Facebook/Instagram Online Search Referral
If referred, by who?
Your History
Are you currently under the care of a physician? *

YES NO
Have you experiences any of these health conditions in the past or present?

Hormone Imbalance Cancer/ Systemic disease High Blood Pressure Diabetes Heart problem Arthritis Auto-immune Disorder Asthma Epliepsy/Seizures Cold sores HIV/AIDS Lupus Depression/Anxiety Headaches/ Migranes None
Any known allergies? *

Asprin Latex Fruits Shellfish Lidocane Fragrance/essential oils Tree Nuts Dairy Sunscreen Pollen None
Have you ever received any botox or fillers? if so, where and when?
Have you ever experienced claustrophobia?

YES NO
Your Skin
What do you wish to achieve with your skin’s health and appearance?
What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture) Sensitive (reactive to fragrance, often irritated) Combination (oily and dry patches, oily t-zone, hormonal breakouts) Oily (enlarged pores, excessive oil) Acne (cystic or nodules) Dry (dull, visible lines and wrinkles, feels tight)
What skin care products do you use on a daily basis? *

Soap Cleanser Toner Serum Mask Exfoliant (physical or chemical) Eye Cream Moisturizer SPF Vitamin A (retinol)
How often do you receive facial treatments?
Do you experience routine breakouts or acne?

YES NO
Have you been diagnosed with eczema, psoriasis or rosacea?

YES NO
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaring Threading Laser/Electrolysis
Do you currently use:

Accutane Retin-A Prescribed topical cream
What brands of products do you currently use? What do you like in your current home care routine? What do you feel could be improved in your home care routine?
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last month YES, within the last 2-3 months NO
What medications, herbs, and vitamins do you take?
How many ounces of water do you drink per day?
What does your diet typically consist of?
From 1-10, rate your stress level
Do you?

Wear contact lenses Have a pacemaker Have metal implants Smoke Consume Alcohol Consume Caffeine Frequent tanning beds
If Applicable,
Are you taking birth control?

YES NO
Are you pregnant or breast-feeding?

YES NO
Your Service

Pick your experience
Conversation preferences

I prefer to discuss my goals during our treatment and be informed of what you’re applying to my skin. I prefer to relax and keep conversation to a minimum.
Your Promise
I acknowledge that I must adhere to Elle Marie Spa's policies:

Cancellations: We allow cancellations 24 hours prior to your appointment. Cancellations less than 24 hours will result in a 50% charge and a No Show will result in a 100% charge on your gift card or credit card.

Check In: Please check in at least 10 minutes prior to your reservation. If you arrive late for your appointment, you risk having your appointment shortened so that we can accommodate the next scheduled guest.

Gratuities: The price of your service does not include gratuity. We recommend a 15% to 20% gratuity for your service provider.

We thank you in advance for respecting these and look forward to making your day amazing!
I agree
Signature

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Elle Marie Spa

Your History

Your Skin

If Applicable,

Your Service

Your Promise