Spa Service Client Intake Form

Client Name*

First NameLast Name

Age/Date of Birth*

Occupation*

Gender*

Phone Number*

Email

example@example.com

Physician Name*

Physician Phone Number*

Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Person*

First NameLast Name

Emergency Contact Phone Number*

Relationship to the Client*

Do you have any of the following conditions?*

Have you ever had an adverse reaction after using skin care product? (Please check all that apply)*

Have you ever had an allergic reaction to any of the following? (Please check all that apply)*

If you've had an allergic reaction to any of the above, please explain.

Are you wearing any eye contact lenses?*

YesNo

Have you been exposed to the sun or used a tanning bed in the last 48 hours?*

YesNo

How frequently are you exposed to the sun or use a tanning bed?*

InfrequentlyFrequentlyRegularly

Have you been under the care of a physician, dermatologist, or other medical professional within the past year?*

YesNo

Do you have any metal implants or wear a pacemaker?*

YesNo

Any skin cancer? (If yes, please explain below.)*

YesNo

If yes to the question above, please explain.

Have you had any piercings, tattoos, or permanent cosmetics? (If yes, please explain WHERE on your person below.)*

YesNo

If yes to the question above, please explain.

Have you ever had a body spa treatment before? (If yes, please specify WHEN below.)*

YesNo

If yes to the question above, please explain.

Are you smoking? If yes, how many packs a day?*

Are you wearing any implantable medical devices? If yes, what are these devices?*

Has your physician discussed concerns about raising your body temperature? If yes, please explain below:*

Do you follow a restricted diet? If yes, please explain/ below:*

Do you follow a regular exercise program?*

YesNo

List any over-the-counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly below:*

Are you currently taking any medications? If yes, please list them below:*

Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:*

Were you previously hospitalized? If yes, please indicate when and why:*

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferring, Glycolic Acid, AHA, Salicylic Acid, or Retinol/vitamin A derivative products? If yes, please list them below:*

Have you used any of the products listed above in the last 3 months?*

YesNo

Have you used an acne medication? If yes, please specify WHEN and WHICH DRUG?*

Do you have Hyperpigmentation (darkening of the skin), Hypopigmentation (lightening of the skin) or marks after physical trauma? If yes, please specify describe.*

Do you form thick or raised scars from cuts or burns?*

YesNo

Do you experience any problems sleeping?*

YesNo

How many hours do you typically sleep each night?*

Have you ever experienced claustrophobia?*

YesNo

Do you suffer from sinus problems?*

YesNo

What is your daily consumption of Water?*

What is your daily consumption of Caffeine?*

What is your daily consumption of Alcohol?*

How do you manage stress? Please elaborate:*

Are you breastfeeding or nursing?*

YesNoN/A

Are you lactating?*

YesNoN/A

Are you pregnant or trying to become pregnant?*

YesNoN/A

Are you taking oral contraceptives? If yes, please specify.*

Any recent changes to or from your contraceptive treatment? If yes, please explain. *

Any menopause problems? If yes, please explain. *

I have read, understand and completed this questionnaire truthfully.
I confirm that all information given in this form is true, complete, and accurate.
I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures.
I understand that witholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.
I am aware that it is my responsibility to inform the esthetician/skin care professional of my current medical or health conditions, and update this history.
The treatments I receive here are voluntary, and I release this organization and/or skin care professional from any liability and assume full responsibility thereof.
I release this organization and/or skin care professional from any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.

ADDITIONAL TERMS

Underage Clients – Parental/Guardian Consent: If a client is under the legal age of 18, parental or guardian consent is MANDATORY for any treatment to be provided. This consent must be given in the form of a signed agreement by the parent or legal guardian, which acknowledges understanding and acceptance of the procedures and terms of service.
Verification of Consent: We reserve the right to request proof of age and verify the consent for any client who appears to be underage. This is to ensure compliance with our policies and legal obligations.
Responsibility of the Parent or Guardian: The parent or guardian who provides consent is also responsible for ensuring the underage client understands the nature of the services to be provided and agrees to the treatment.
Non-compliance with Age Requirement: In the event that a client has misrepresented their age or fails to provide the required parental or guardian consent if underage, we reserve the right to refuse service. Any deposits or payments made in such cases may be subject to forfeiture in accordance with our cancellation policy.

Patient/Client Name*

First NameLast Name

Signature of Patient/Client

Date Signed *

Date

Spa Service Client Intake Form

Client Data

Medical / History Data

Female Clients

Authorization