Sundara Holistic Wellness

Sundara Holistic Wellness

Facial Intake Form
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Walked byFacebook/InstagramOnline SearchReferral
If referred, by who?
Your Medical History
Are you currently under the care of a physician?

YesNo
Have you experiences any of these health conditions in the past or present?

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther
Any known allergies?

AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySunscreenPollenNoneOther
List medications/supplements you are currently taking.
Have you ever received any botox or fillers? if so, where and when?
Have you ever experienced claustrophobia?

YesNo
Please rate your stress level.

LowMediumHighNone
Your Skin
What are your skin concerns?
What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
What skin care products do you use on a daily basis?

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
Do you experience routine breakouts or acne?

YesNo
Have you ever been diagnosed with eczema, psoriasis or rosacea?

YesNo
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis
Do you currently use:

AccutaneRetin-APrescribed topical cream
Please specify which product or type, if you answered YES to the question above.
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO
Do you?

Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
Females Clients
Are you taking birth control?

YesNo
Are you pregnant or breast-feeding?

YesNo
I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of a package or 50% of the total service cost. I acknowledge that ANY no show will result in the loss of a package or 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “No-show” policy.
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Chateau Glow and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
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Sundara Holistic Wellness

Your Medical History

Your Skin

Females Clients