Spa Intake Form

Spa Intake Form
Patient Data

Please fill out this form accurately for the best possible results.
Is this your first service with Amita Bliss and if not, what was your last service?
What is the service you are requesting ?
What are the improvements you would like to see?
Patient Name

First NameLast Name
Age
Gender
Phone Number
Format: (000) 000-0000.
Email
example@example.com
How would you like us to contact you for appointment reminder? Text/Email
Medical / History Data
Do you have any of the following conditions?
Do you have any known allergies or reactions to products, food, medicine, latex?
Are you wearing any implantable medical devices? If yes, what are these devices?
Do you wear contact lenses?
Are you pregnant, breastfeed, or nursing?
Do you have mobility issues or disabled? If yes, please list them below:
Are you currently taking any medications, vitamins, treatment protocols for skin or general health? If yes, please list them below:
Have you ever had a facial, massage, body wrap, dermaplane or skin peel ?
Have you had botox, fillers, implants, laser resurfacing, facial surgery or any procedure with a medical device ? If yes, please indicate below.
Do you tan or use tanning beds?
what is your skin condition? Check all that apply.

Other
Heredity is an important factor in determining any skin treatment, check all that apply.

Other
In the last 14 days have you had a chemical peel, facial wax, dermaplane, used retinol products, tretinoin, laser resurfacing or any procedure with a medical device? If yes please list below.
Authorization
- I confirm that all information given in this form is true, complete, and accurate.
- I release this organization and place where proceedure is given from any responsibility in case of accident, illness, injury or death.
- I acknowledge that no assurance was offered about the outcome.
Signature of the Patient
Should be Empty:

Spa Intake Form

Patient Data

Medical / History Data

Authorization