Client Intake Form

CLIENT INTAKE FORM

Thank you for choosing Roselux Spa! To ensure that we provide you with the best possible experience, please complete the following client intake form. Your responses will help us tailor the facial to your unique skin type and concerns.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you hear about Roselux?*
If you were referred to us by an existing client, please kindly provide us with their name below.
How would you describe your skin type?*

DryOilyCombinationSensitiveNormal
Which of the following skin care concerns apply to you? Please select all that apply.*

Textured skinHyperpigmentationAcne scarringRosaceaFine lines and wrinklesMelasma or sun damageUneven skin toneRednessUnwanted hairExcessive oil and shineSensitized skin: referring to skin that is temporarily reactive, due to excessive use of active treatments and/or ingredientsOther
When was your last facial?*
Are you currently taking any medications or vitamins that may affect your skin or the facial service? (e.g., Retin-A, Accutane, antibiotics, thyroid medication, diabetic medication, etc). Please list so that I can provide you with the best options for your service:*
Have you refrained from using any AHA/BHA acids, exfoliating products, or skincare items containing retinoids for at least 5-7 days prior to the treatment?*

YesNo
Have you received any of these hair removal services in the last 7 days? Please note, if you have received any of the services in the last seven days, you will not be able to get any facial service/chemical peel. A facial service can be conducted if it’s been more than 7 days.*

WaxingSugaringThreadingElectrolysis/LaserDepilatory creamShavingNONE of the above
Do you have any sunburn on the area that will be treated? Please note that having a facial immediately after a sunburn can cause your skin to react to active ingredients, which may require rescheduling of the appointment. If you have a sunburn, please contact me to reschedule your appointment.*

YesNo
Do you have any health conditions or allergies that we should be aware of before your facial service? (e.g. hormone imbalance, auto-immune disorder, diabetes, HIV/AIDS, frequent cold sores, Hepatitis, Cancer/Systematic Disorder, Arthritis, etc). PLEASE LIST:*
In order to provide the safest and most effective facial treatment, it is important for us to be aware of any recent medical procedures you may have undergone. Please list any medical treatments or procedures you have received on your face or neck within the past 6 months. This includes, but is not limited to, surgeries, laser therapies, chemical peels, microneedling, microdermabrasion, and any other relevant treatments. This information will allow us to tailor the facial to your specific needs and ensure we avoid any potential complication. If NONE, please note “NA” or “NONE”. PLEASE LIST:*
Do you have any metal implants, piercings, or a pacemaker that may affect the use of certain facial modalities?*
Do you have any allergies? If so, please list below:
In the past 14 days, I have not received any injectables (e.g. dermal fillers, Botox, Dysport, Juvederm, etc).*

Yes, I have.No, I have not.
Are you currently pregnant or breastfeeding?*

YesNo
Facial Service Preferences - Do you have any specific preferences for your facial service (e.g., massage pressure, aromatherapy, music)? Please let us know:
What are your skin care goals?
Which products do you currently use in your skin care routine? Please try to name the brand(s) of each (e.g. cleanser, moisturizer, toner, SPF, serums, lip products, eye products, exfoliator, etc).*
I confirm that I am not currently experiencing any viral, bacterial or fungal infections such as cold, flu, warts, fever, cold sores, or skin infections. If you are experiencing any of these symptoms, please contact me to reschedule the appointment.*

Yes, I am experiencing these symptoms.No, I am NOT experiencing these symptoms.
I agree to give my esthetician Jennifer Hinostroza and Roselux Spa the permission to take photographs of the and/or digital images of me for promotional or marketing purposes on social media platforms including but not limited to Instagram, Facebook, TikTok, and to track process between treatments. I understand that my identity will be kept confidential unless I provide permission to use my name or likeness. I have read and understood the terms of this consent and voluntarily agree to it.*

I agreeI disagree
Please be advised that if you are more than 15 minutes late to your scheduled appointment, your appointment may be cancelled and you may be charged 100% of the total service fee. This policy is in place to ensure that we are able to accommodate all of our clients in a timely manner. We appreciate your understanding and cooperation*

I agreeI disagree
Please note that cancellations or rescheduling of appointments with less than a 48-hour notice of the scheduled appointment time may be charged 50% of the total service fee to the card on file. In the event of a no call/no show, 100% of the total service fee may be charged. If the charge is declined on the card on file, you will be unable to rebook your appointment until the past balance is paid in full. We appreciate your understanding and cooperation.*

I agreeI disagree
By signing below, I acknowledge, understand and agree that:
- I have completed this form to the best of my ability and knowledge.
- I give my esthetician permission to perform any facial treatments as agreed upon.
- I will inform my esthetician of any changes in the above information.
- I certify that I do not have any medical condition(s) that would make the requested treatment unsuitable.
- I agree to inform my esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly.
- I hereby release, waive, and discharge all liability toward my esthetician and Roselux Spa for any injury or damages incurred due to any misrepresentation of my health.
Signature*

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Parental Consent for Minors (Under 18 Years Old)

If the client is under the age of 18, a parent or legal guardian must provide consent for the facial service.

I, the undersigned, certify that I am the parent or legal guardian of the above-named minor. I hereby give my consent for him/her to receive a facial service at Roselux Spa. I understand that all procedures will be explained to my satisfaction, and I will be given the opportunity to ask any questions regarding the service.

By signing this form, I acknowledge that I have read and understood the information provided and agree to the terms and conditions outlined by Roselux Spa. I also confirm that the information provided is accurate to the best of my knowledge.
Signature of Parent/Guardian:

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Full Name of Parent/Guardian:

First NameLast Name
Parent/Guardian Contact Number (required for minors):
Should be Empty:

CLIENT INTAKE FORM