• GemSpa Client Consultation Form

  • Birthdate
     - -
  • Format: (000) 000-0000.
  • Does your job require you to work outdoors?

  • Your Skin Care

  • Have you had a facial treatment before?
  • Have you had a body spa treatment before?
  • Which of the following best describes your skin type? (Please check one)
  • Do you have any special skin problems or concerns pertaining to your face or body?
  • Have you ever had chemical peels, laser treatments, or microdermabrasion?
  • In the last month?
  • Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/Vitamin A derivative products?
  • Do you use acne medication?
  • Have you experienced Botox, Restylane, or collagen injections?

  • What skin care products are you currently using?

    List brands if known

  • Cleanser
    Toner    
    Day Moisturizer      
    Night Moisturizer      
    Exfoliator      
    Mask      
    Eye Product      
    SPF/Sunscreen      
    Scrubs      
    Makeup Products      
    Soap      
    Shower Gels      
    Body Lotions    
    Other      

  • Have you used any hair removal methods in the past six weeks?
  • Check all that apply
  • What areas of concern do you have regarding your: SKIN
  • What areas of concern do you have regarding your: EYES
  • What areas of concern do you have regarding your: LIPS
  • Have you ever had an allergic reaction to any of the following:
  • Have you recently used any self-tanning lotions, creams or treatments?
  • Have you had any recent tanning bed or sun exposure that changed the color of your skin?

  • Lifestyle

  • How many glasses of water do you drink per day?
  • How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?
  • How many alcoholic beverages do you consume per week?
  • How many hours of sleep do you get per night?
  • Which foods do you consume on a regular basis?
  • What does your daily commute look like?
  • How often do you travel on a plane?
  • How many hours do you spend in front of a screen or digital device?
  • Do you exercise on a regular basis?
  • Do you smoke cigarettes, vape, or consume other tobacco products?

  • Female clients

  • Do you use oral contraceptives?
  • Any recent changes to or from your contraceptive treatments?
  • Are you pregnant or trying to become pregnant?
  • Are you experiencing any menopausal symptoms?
  • Are you undergoing any hormone replacement therapy treatments?

  • Male Clients

  • Do you experience irritation from shaving?
  • Do you experience ingrown hair as a result of hair removal?

  • Future Appointments/Contact

  • May I call you at the provided phone number to confirm future appointments?
  • May I contact you via mail/email about future appointments and news?

  • I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that is supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contradications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof. 

  • Should be Empty: