New Client Consultation Form

  • New Client Skincare Consultation Form

    Please answer the following questions to the best of your ability. This form MUST be filled out & be placed on file before we begin your first appointment with Skin & Massage Spa By Bella.
  • Date*
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  •  -
  • How did you hear about us?*
  • Please select all the options that interest you or that you have questions about:

  • Your Skin

    Please fill this part as accurately as possible.
  • What are your skin care challenges?*

  • Have you ever had a facial or skin treatment before?*
  • How often do you wear makeup?*
  • What Skin Care Products do you currently use?*

  • Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so we can best answer any questions on ingredients and help you meet your skin goals. 

  • Do you/have you used Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
  • Have you received any of these services in the last 60 days?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?

  • Please check any topical or oral medications you are currently using or have used in the last 6 weeks.*
  • Any known allergies?*

  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*

  • WOMEN CLIENTS

    About birth control:

    Avoid low-estrogen birth control pills, Norplant, Provera, and Depo-Provera if you are acne-prone. Premarin progesterone hormone replacement can also be problematic. If you have polycystic ovaries, they will cause hormonal changes and breakouts. Taking birth control pills can delay the onset of acne, and once you decide to stop taking them, you may experience the acne you would have had before you took them. We call this method the "band-aid approach to acne."

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy? *

  • MALE CLIENTS

  • What is your current shaving system?
  • Do you experience irritation from shaving?

  • Post-Treatment Care Instructions:

    • Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours.
    • Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds).
    • If some sun exposure cannot be avoided first apply a broad-spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skincare regimen as the skin can potentially become more sensitized to the sun as a result of this treatment.
    • Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer.
    • Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity.
    • Consult your skin therapist before resuming topical treatments.
    • Chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post-treatment.
    • DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
  • I have read the post care instructions and agree to adhere to them*
  • I agree and consent to having before and after pictures or videos taken for my skin journey. I understand that some photos, may be used for promotion and marketing / social media purposes. I fully understand that Skin & Massage Spa By Bella will never tag or mention my name or any relation to my identity to the public without my permission.

  • Late Policy – Skin & Massage Spa by Bella

    Each session at Skin & Massage Spa by Bella is reserved exclusively for you. To respect every client’s scheduled time, we allow a 10-minute grace period for late arrivals.

    If you arrive within 10 minutes of your scheduled start time, your session will be shortened accordingly and will still end at the original time—ensuring that our next client is not delayed.

    If you arrive more than 10 minutes late, fail to cancel with at least 24 hours' notice, or do not show up for your appointment, the full-service fee will be charged. For clients on a prepaid package, one session will be deducted, and no makeup appointment will be provided.

    We kindly ask that you notify us as soon as possible if you anticipate being late. Your cooperation helps us maintain a relaxing, punctual, and professional environment for everyone.

    Thank you for your understanding and continued support.

  • Please carefully read through and check each one of the choices below to continue with your treatment:*

  • Skin & Massage Spa By Bella

    8543 South Redwood Road, Suite A

    West Jordan, Utah 84088

    skinspabybella@gmail.com

    801-837-8304

    www.skinspabybella.com

     

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