Form
Skin Analysis & Consultation
Please answer the following questions to the best of your ability. This form MUST be filled out & be placed on file before we begin your first appointment. If any changes need to be made to your file at any time, I ask that you please let me know as soon as possible. Thank you!
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Birthday
*
/
Month
/
Day
Year
Date
How did you hear about Refine Skin Spa?
*
Please Select
Google
Instagram
Facebook
Referral (please provide name below)
Other
Name of Referral
First Name
Last Name
Back
Next
What is the purpose of your appointment today? (please select all that apply)
*
Reduction of fine lines/wrinkles
Reduction of oil/acne
Reduction of brown spots/sun damage
Reduction of redness
I need help with my skin's texture
I am interested in Procell Therapy
I am interested in a Hydro-Facial
I am interested in hearing about skincare products
I am interested in relaxation
I am interested in Dermaplane
I am interested in LED Light Therapy
The following information is essential to optimize the results of your service. I am currently experiencing...
*
Acne Scars
Breakouts
Dry/Flaky Skin
Redness/Rosacea
Black Heads
Finelines/Wrinkles
Hyperpigmentation
Uneven Skin Tone
Oily Skin
Unwanted Hair
Milia
Sunburn
Dull Complexion
Sensitive Skin
How often do you wear makeup?
*
Never
1-2x a week
3-4x a week
4-5x a week
Everyday
Special Occasions Only
Back
Next
Select what types of make up you wear?
*
Foundation
Primer
Pressed Powder
Loose Powder
BB or CC cream
Bronzer
Blush
Highlighter
Eyeshadow
Lipstick
Eyeliner
Other
No Makeup
What type of work do you do?
*
What is your genetic background?
*
ex.Hispanic, German, Indian, French
Do you take any supplements/vitamins?
*
Please list all.
Are you currently...
*
Pregnant
Trying to become pregnant
Nursing
None of the Above
Do you take birth control?
*
If yes please list what type and what kind.
Do you have any allergies? (please check all that apply)
*
Aspirin
Salicylates
Milk
Apples
Pumpkin
Citrus
Iodine
Latex
Fish
Grapes
Adhesive
Medical Tape
None
Other
Do you exercise?
*
Yes
No
If so, how often?
1-2x a week
3-4x a week
4-5x a week
6+ days a week
Do you use tanning beds?
*
Yes
No
When you go into the sun, do you (choose one)
*
Always burn (I)
Usually Burn (II)
Sometimes Burn (III)
Rarely Burn (IV)
Very Rarely Burn (V)
Never Burn (VI)
How often are you in the sun?
*
30 min- 2 hours a week
3-5 hours a week
5+ hour a week
Never
Back
Next
Skincare Routine & Products
Please list all products (including brands) you use morning and evening. This helps me understand the current condition of your skin, how these products maybe effecting your skin and what should be added or deducted to your routine so please be specific.
Morning Routine & Products
*
Evening Routine & Products
*
Do you wear SPF daily? Excessive sun exposure can cause breakouts to end up as dark scars because of the sun’s UV rays, which increases inflammation, redness and creates new breakouts. Daily SPF decreases your risk of skin cancer & helps prevent premature skin aging, fine lines / wrinkles, discoloration, etc.
*
Yes, I do
No, I don't
I need help choosing one thats best for me
My skin type is...
*
Normal
Dry/Dehydrated
Oily
Acne Prone
Rosacea/Red
How do you currently feel about the over all quality of your skin?
*
1 (bad)
2
3
4
5
6
7
8
9 (fantastic)
Photo Release Agreement
In order to assist the esthetician with your skin care treatments, it is sometimes necessary for the esthetician or a member of the staff to take photographs of your face and/or area to be treated. These photos become the property of Refine Skin Spa and will remain in your patient file only. None of these photographs will be viewed by anyone outside of the staff without your expressed prior written consent.
I agree to the use of my results as marketing on their website, Instagram, Facebook or promotional flyers in the event Refine Skin Spa would like to publish them.
*
I agree
I do not agree
If agreed, by signing below I have entered into this photo release freely, I understand and voluntarily agree to the terms.
Please Note
All Information provided above will be held in strict confidentiality information is used by service provider to ensure quality and safety of clients.
Back
Next
Before Your Treatment
Do not have another facial treatment done within 7 days, unless recommended by physician. Wait time is minimum 7-14 Days in between professional services (Laser, IPL, Microdermabrasion, Hydrodermabrasion, etc.)If you are using or have used Accutane in the past 6 months, we may not be able to perform a facial treatment (yet).If you are using or have used any form of tretinoin in the past 6-8 weeks, we may not be able to perform a facial treatment (yet).
*IMPORTANT* to avoid complications and/or irritations, please stop using retinoids and retinol, glycolic acids, benzoyl peroxide, astringents at least 48 hours in advance. Please let us know if you have used any of these before your appointment. Do not wax, tweeze or use depilatory creams 3-7 Days to your facial treatment. DO NOT use tanning beds, have prolonged sun exposure or sun burns within 7 days of your treatment.
Please read through carefully and check each box to move forward with your treatment agreement.
*
I agree not to use any exfoliants or get any other facial service done on myself within 7 days of my service with Refine Skin Spa.
I agree not to use tanning beds or be exposed to direct sunlight without SPF for 24-48 hours following my treatment.
I agree to be gentle with my skin after my treatment and let my esthetician know if I have any concerns with my skin post service.
I acknowledge that al of the information provided by me above is true and correct to the best of my knowledge.
I understand that some skin conditions may require more than one treatment and home care products to achieve the desired results. Results can not be guaranteed due to individual skin types and conditions as well as compliance.
As the client, I take full responsibility for making my service provider aware of any mental or physical conditions I have that my compromise the results of my treatment. I understand my treatment is therapeutic in nature and I will alert my service provider immediately should I feel any discomfort.
As the client, I fully understand that by signing this agreement, my cell phone and smart watch should be silenced and/or turned off during my service, as there should be no interruptions. I agree to these terms so that my service provider and I can pay full attention to the importance of the service.
I agree to not have anyone but myself present at my appointment, unless previously discussed with my service provider. I am aware that I maybe asked got reschedule my appointment if anyone other than myself is present at my appointment and they are unable to sit in the lobby without an adult present.
I agree to be on time to my appointment and understand that I maybe asked to reschedule my appointment if I am late and my service can no longer be performed or it interferes with the client after mines appointment.
I understand that my card on file will be charged 50% of my service fee for canceling less than 24 hours than my appointment time and date.
I understand that my card on file will be charged 100% of my service appointment should I not show up to my appointment.
Date
*
/
Month
/
Day
Year
Date
By signing below I have read and fully understand Refine Skin Spas policies and agree to adhere to them. Should I have any questions or concerns, I will let my service provider know BEFORE my service.
*
Submit
Submit
Should be Empty: