Intake Form

Today's Date

Date

Name

First NameLast Name

Birthdate:

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation:

Emergency contact and relation to contact:

What is the best way we can reach you?

Phone CallText MessagesE-mail

How did you find about us? (If an individual, please include their name.)

Please indicate which of the following you are interested in (Check as many as you want)

What are your goals with your skin?

If you are currently experiencing or being treated by any health or skin-related condition/disorder, please describe:

Please indicate if you have ever used any of the following medications for skin treatment (check all that apply)

What condition were you treating with this medication, and when was the last time it was used?

Do you have any known allergies? Also list any skin treatments you have used that caused an unexpected reaction.

Please list all over-the-counter medication, supplements, and/or prescription medications you are currently taking.

Your skin is (Check all that apply):

What is your ancestry, if known:

Ex: European, Asian, Idian, etc.

What skincare products are you currently using? Please list what type of product (cleanser, toner, etc). Be as detailed as possible.

Are you currently using daily sunscreen?

YesNo

Skin Concerns:

Most recent Facial / Treatment / Procedure:

How often would you like to come in for treatments?

Do you receive Botox/Filler? If yes, when was the las time?

Do you use tanning beds?

YesNo

Do you smoke or vape tobacco?

YesNo

What is your stress level?

From 1 to 10

How often do you exercise? What exercises interests you?

How much water do you drink daily?

What is your average hours of sleep?

Please indicate any of the following that apply to your eating habits:

Which is your favorite essencial oil?

LavanderLemongrassRosemaryAll the above

What type of drinking water do you prefer?

Flat WaterSparkling WaterNo Water

Would you like the bed heated?

YesNo

Are you claustrophobic?

YesNoNot Sure

Questions / Anything you want us to know

I consent to "before and after" photos for the purpose of documentation, potential advertising and promotional purpose.

Yes to allDocumentation Only

This form is designed so we can get to know you better! Your credit card information is necessary to have on file to hold all appointment time(s).

Please note, you will not be charged unless you have received a service or cancel/reschedule within 48 hours of the start of your scheduled appointment time(s). If you are not present for a scheduled appointment or do not provide 48 hour notice, you will be charged 50% of your scheduled service(s) as the fee. You may cancel online or by calling the spa directly.

Consent: It is my choice to receive spa service. I understand and voluntarily accept the risks associated with all services. I agree that this waiver is in effect for all services, and will not expire unless specifically requested by either party. By signing this form, I agree to the above terms, authorizing the spa to retain my personal information on my private client account, and release the spa and its employees from any liability or claims.

We will not treat clients with: questionable medical conditions, open wounds or sores, infections recent dental work, healing incisions, etc.

I understand that the treatments I receive are not substitution for medical treatment.

Defective products must be returned within 1 week of purchase.

All sales are final.

Signature

Intake Form

Medical History

Skin Analysis

Lifestyle

Preferences

Client Consent