Facial
Your treatment may include the following: enzymes, acid peels, microdermabrasion, dermaplaning, extractions, microcurrent, galvanic, high frequency, ultrasonic, LED light therapy, oxygen therapy and other treatment modalities as necessary.
Name
*
First Name
Last Name
Contact
*
Phone Number
Email Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Employer / Occupation
*
Employer
Occupation
Emergency Contact
*
Full Name
Phone Number
How did you hear about Sherrielee Holistic Skin Spa?
*
Have you ever had a Facial before?
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Yes
No
When was your last facial? (if this is your first facial, use todays date)
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-
Month
-
Day
Year
Date
Have you had any of these health conditions in the past or present (Please check all that apply)
Anemia
Any Active Infections
Asthma
Arthritis
Blood clotting disorders
Cancer
Gout
Diabetes
Emotional Disorder
Epilepsy Seizures
Fainting Spells
Gallstones
Heart Disease
Heart Attack
Herpes
Hepatitis
HIV/AIDS
Rheumatic Fever
High Blood Pressure
Digestive Problems
Ulcerative Colitis
Kidney Disease
Liver Disease
Sleep Apnea
Skin Cancer
Use a C-PAP machine
Thyroid Problems
Tuberculosis
Venereal Disease
Neurological Disorders
Bleeding Disorders
Lung Disease
Emphysema
Keloid Scarring
Skin Disease/Skin Lesions
Metal bone Pins, Plates or Pacemaker
Cerebrovascular Disease
None
Are you pregnant?
*
Please Select
Yes
NO
Are you adding Dermaplaning?
*
Yes
No
If yes to Dermaplaning, please initial or put "N/A" for No.
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I understand that contraindications to dermaplaning include current or recent use of accutane, eczema, dermatitis, malignant skin tumors, open lesions, lupus, active herpes infection, sunburn and keratoses, allergy to nickel, Blood thinners. I understand there is a risk of injury and I agree to assume those risks. These risks include irritation, dryness and redness of the skin being treated. Due to the use of a surgical blade in this treatment, there is a chance that they may obtain a superficial scrape or nick on the skin. Possible side effects of the treatment area can include mild redness of the skin, irritation, and dryness.
Are you adding Micro-current?
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Yes
No
If Yes to Micro-current, please initial or put "N/A" for No.
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I understand there are certain contraindications that would preclude me from receiving microcurrent treatments, including autoimmune disorders, diabetes, embolism, epilepsy, melanoma, metal implants including plates/pins/screws, open wounds, pacemaker, pregnancy, and varicose veins. I understand that microcurrent treatments involve conducting mild electrical currents through the body, and that this brings some inherent risk. I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations. I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.
What type of skin do you have?
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Normal
Oily
Dry
Combination
What is your goal for having a facial today?
What areas of concern do you have regarding your skin? (click all that apply)
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Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness/Ruddiness
Dehydrated
Brown Spots
No concerns, just want to relax
Have you been under the care of a Dermatologist within the past year?
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Yes
No
If Yes to seeing a Dermatologist, please explain or put "N/A" for No.
*
Do you or have you used Accutane within the last year?
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Yes
No
If yes to Accuntane, when? or just put "N/A" for No.
*
Do you wear contact lenses?
Yes
No
Have you ever had an allergic reaction to any of the following?
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Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
No Allergies
If Yes to allergies, please describe or put "N/A" for No:
*
Signature / Parent Signature
Submit
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