New Client Consultation Form

New Client Intake Form

Intake form must be completed before rendering service.
Name*

PrefixFirst NameLast NamePreferred Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number*

Area CodePhone Number
E-mail*
example@example.com
Date of Birth*
How did you hear about us?*

Website / Online SearchFacebookInstagramReferralOthers
If Referral, please list name
Do you consent to Infinity Spa taking your picture or video for advertising purposes?

YesNoYes, but no face (For Body Treatments).Yes, but cover my eyes (For Facials).
What type of service are you getting today?*
Your Skin
What are your skin care goals?*

Acne FreeWrinkle FreeBrighterYounger LookingOther
What are your skin challenges?*

Wrinkles / Fine Lines/ AgingHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / Rosacea/ SensitivityBlack HeadsDry/ FlakyOther
Have you ever had a facial or skin treatment before?*

YesNo
What Skin Care Products do you currently use?
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Are you allergic to anything food, medicine and/or etc?

YesNoOther
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesWear contact lensesNoneOtherPaceMakerMetal Implants
If you checked YES to any of these please provide further information. If not mark, NA*
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues? *

YesNoN/A
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
PLEASE READ CAREFULLY: I understand that by signing this questionnaire, I have provided complete and truthful information. I acknowledge that this disclosure supersedes any previous verbal or written disclosures and that withholding information or providing false information may lead to adverse reactions or skin irritation from the treatments received. I have made a voluntary decision to undergo this treatment/procedure after receiving an explanation of its nature, purpose, as well as the associated risks and hazards from Infinity Spa Jax. While it is not possible to outline every potential risk and complication, I have been informed about the benefits, risks, and potential complications involved. I understand that individual results may vary depending on factors such as age, skin condition, and lifestyle, and that additional treatments may be necessary to achieve the desired outcome at an extra cost. I affirm that I have provided an accurate account of my medical history, including any known allergies, and disclosed all prescription drugs or topical products that I am currently using or ingesting. By reading and fully comprehending this agreement and the information provided above, I acknowledge my awareness of the procedure and accept its associated risks. I am satisfied with the answers to my questions and consent to the terms outlined in this agreement. I understand that any undisclosed present conditions that may be affected by today's treatment are not the responsibility of the esthetician or Infinity Spa Jax.*

Yes
By signing below, I acknowledge and authorize Infinity Spa Jax to charge my card for the requested treatment. I understand that Infinity Spa does not offer refunds, and any missed appointment or cancellation will not be eligible for a refund. I fully authorize Infinity Spa Jax to charge my card for the agreed-upon treatment, and I acknowledge that no refunds will be provided under any circumstances, whether due to my own fault or that of Infinity Spa.

Furthermore, I am aware that initiating a chargeback through my bank will result in the use of this consent as evidence, and I acknowledge that such action may prohibit me from making future bookings with Infinity Spa.
Signature*

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New Client Intake Form

Your Skin

Your Health