Service Intake Form
Please Complete This Form No Later Than 24hrs of Booking Service, not Prior To Service. Services will not be booked if deposit sent through invoice, nor Service Intake Form is not received.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Civil Status
Single
Married
Divorced
Widowed
Occupation
What Service would you like to book?
I AM SCULPTED
I AM REVIVED
I AM ELECTRIC FEEL
I AM EARTH
I AM WIND
I AM FIRE
I AM H20
Face and Body?
Just Facial Treatment
Just Body Treatment
Face and Body Treatment
Face and 1 Area Of The Body
1 Area Body Treatment
More Than 1 Body Treatment
Do you have any of the following conditions? If yes, please select them:
Cancer
Hypertension
Hypotension
Metal Implants
Pacemaker or Defibrillator
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hysterectomy
Hormonal Imbalance
Epilepsy or Seizures
Blush Easily
HIV AIDS
Hepatitis A/B/C
Migraines/Headaches
Depression/Anxiety
Psoriasis
Rosacea
Eczema
Bruise Easily
Spinal Cord Injury
Immune Disorder
Lupus
Keloid Scarring
Blood Clot Disorder
Skin Disease
Fibromyalgia
Menopause
Circulation Disorder
Varicose Veins
Other
Skin condition
Normal
Oily
Dry
Acne
Not Sure
Other
How does your skin heal?
Fast
Pigments
Scars
Slow
Other
What is your skin concern?
Scaring
Dryness
Oiliness
Acne
Firmness
Fine Lines
Uneven Tone
Under Eye Fatigue
Maintenance
Not Sure
Most of these concern me
Have you recently experienced any injuries or been under surgery in the past 6 months? If Yes, Please give a brief description.
How do you take care of your skin at home?
How do you take care of your skin at work?
Do you consume alcohol?
Yes
No
Are you pregnant?
Yes
No
Are you trying or planning to be pregnant?
Yes
No
Are you taking any contraceptive pills?
Yes
No
Are you breastfeeding?
Yes
No
Do you consume caffeinated drinks?
Yes
No
Are you wearing any contact lenses?
Yes
No
Are you currently under any dietary restrictions?
Yes
No
What beauty or cosmetic products you're currently using?
Are you taking any medications that is related to cosmetic or skin improvement?
Terms & Conditions
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Print Form
Should be Empty: