Elle Marie Spa: Skincare Facial Consent Form

Elle Marie Spa

Skin Services Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number

Area CodePhone Number
How did you hear about us?
If referred, by who?
Your History
Are you currently under the care of a physician?
Have you experiences any of these health conditions in the past or present?

Other
Any known allergies?

Other
Have you ever received any botox or fillers? if so, where and when?
Have you ever experienced claustrophobia?
Your Skin
What do you wish to achieve with your skin’s health and appearance?
What would you say your skin type is?
What skin care products do you use on a daily basis?
How often do you receive facial treatments?
Do you experience routine breakouts or acne?
Have you been diagnosed with eczema, psoriasis or rosacea?
Have you received any of these facial hair removal services in the last 7 days?
Do you currently use:
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?
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?
If Applicable,
Are you taking birth control?
Are you pregnant or breast-feeding?
Your Service

Pick your experience
Conversation preferences

Other
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!
Signature
Should be Empty:

Elle Marie Spa

Your History

Your Skin

If Applicable,

Your Service

Your Promise