Facial with Massage
Client Intake Form
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?
*
Massage / Body work Information
Have you ever had a relaxation massage or body work?
Please Select
No
Yes
If yes, to having a massage when? Put today's date if No.
-
Month
-
Day
Year
Date
What result do you want from your treatment today? (click all that apply)
Relaxation
Stress Relief
Reduce Anxiety
Ease Muscle Tension
All of the above
Are you Pregnant? (Please note, that I am not licensed to do Prenatal massages. I will have to refer you to an LMT.)
Yes
No
Any accidents, injuries or illnesses?
Yes
No
If yes, please explain
If no, please put "N/A"
Please initial that you understand that I am a Licensed Esthetician and licensed to do a “Relaxation Massage”. I am NOT a licensed massage therapist (LMT) and cannot perform deep tissue massage. If you have a serious injury or in any pain, I will refer you to a Licensed Massage Therapist.
*
Facial Information
Have you ever had a Facial before?
*
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
Are you adding Dermaplaning?
*
Yes
No
If adding Dermaplaning please initial. If no, please put "N/A"
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?
*
Yes
No
If adding Micro-current please read and initial. If no, please put "N/A"
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?
*
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (click all that apply)
*
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
None, I just want to be pampered
Have you been under the care of a Dermatologist within the past year?
*
Yes
No
If yes you're under the care of a Dermatologist , please explain
*
If no, please put "N/A"
Have you ever had an allergic reaction to any of the following?
*
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
No Allergies
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?
*
Yes
No
If yes to using Retin-A, Renova, AHA's or Retinol please describe:
If no, please put "N/A"
Signature
*
By signing below, you agree to the following: I have completed this form to the best of my ability and agree to inform the sherrielee skincare, LLC of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and sherrielee skincare for any injury or damages incurred due to any misrepresentation of my health history.
Submit
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