New Client Consultation Form

VVSpa - Facial Consent Form

Please fill out the form before your scheduled appointment.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date*

MonthDayYear
Emergency Contact
Relationship (Of Emergency Contact)
Phone (Emergency Contact)
Please enter a valid phone number.Format: (000) 000-0000.
How Did You Hear About Us?
When was your last facial?*
Are you currently

PregnantBreast FeedingTaking Birth ControlHave any injuriesBotox fillersTaking GlycolicAHA/BHARetin-ARetinolAdapaleneAccutaneDifferinMandelic AcidHave cold soresMenopauseSunburntSmokingHave cancer or systemic diseaseHigh blood pressureDiabetesArthritisEpilepsy/seizure disorderAsthmaHerpes or hepatitisLupusClaustrophobiaDepressedHave anxietyMigrainesWear contactsUsing skin thinning products
Do You Have Any Allergies?
Are You Taking Any Medication or Vitamins?
Best Described Skin Type

SensitiveDehydratedItchy EyesRosaceaFlakingFine lines/wrinklesOily t-zoneOily all overOpen poresWhiteheadsBlackheadsPustulesBroken capillariesFrecklesUnderlying congestionAge or sun spotsEasily burnedHyperpigmentationDark circles around eyesTired eyesFacial hairDullEczemaPsoriasis
What are your skin care goals?
Expectations for today's treatment?
Had chemical peel, laser or microdermabrasion before?

YesNo
Get irritated from shaving?

YesNo
Do you exfoliate?

YesNoSometimes
I have read and filled out the information above. If I have any concerns I will address these to my therapist immediately. I give my therapist permission to perform any facial treatments and will hold her and her staff harmless from any liability that may result from treatments. I also, to my best knowledge, given any accurate account of my medical history, including all known allergies or prescription drugs or products I'm currently ingesting or using topically. I understand my skin therapist will take every precaution to minimize or eliminate any negative reaction as much as possible. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that this document is to provide the best possible guest experience when receiving any treatment from the therapist signed below.*

by checking this box I understand and accept this statement.
Signature*
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VVSpa - Facial Consent Form