Massage & Skin Care by Angela

New Client Intake Form
Today’s Date

MonthDayYear
Name

First NameLast Name
Date of Birth
MM/DD/YYYY
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
area code & number
E-mail
example@example.com
Preferred method of receiving appointment confirmations and reminders?
How did you hear about us?
If Referral, please list name
If Other, please let me know
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Area Code & Phone Number
Your Health
Have you experienced any of these health conditions in the past or present?
Please provided more details you checked cancer, autoimmune or other.
Any known allergies?
Do you?
Are you currently taking any of the following:
Please list any medications/supplements that you are currently taking.
Are you pregnant or trying to become pregnant?
If you are pregnant, how far along are you?
Have you recently had Permanent Cosmetics, Botox, Juvederm, or other dermal fillers in the last two weeks?
If you checked yes to any of these please provide further information.
Massage

Must be completed by all since massage may be incorporated into service
Have you ever had a professional massage treatment before?
If Yes, how long ago?
Rate your stress level:
Goals for your massage today:

Other
Is there any area of the body you would like focus on today?
Is there any area of the body you do NOT want massaged?
Pressure for your massage:
Skincare

Massage Only clients can scroll to bottom to complete the form, everyone else please complete the skincare information. Thank you
What are your skin care goals?
What are your skin care challenges?
Please feel free to go into more detail regarding your concerns.
Have you ever had a facial or skin treatment before?
If Yes, when?
What Skin Care Products do you currently use? (If you are seeking corrective treatments go into details below)
If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, Hydroxy Acid, Vitamin C or Vitamin A or other Vitamin A derivatives?
If you checked Yes, to the above, what product(s)?
Have you received any of these hair removal services in the last 30 days?
If you shave, any skin issues?
Are you a smoker?
Have you ever received chemical peels, laser services, microdermabrasion or any other resurfacing treatments?
Policy Disclosures & Disclaimers

Must be completed by everyone.
Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required to hold your appointment. In the event of cancellations received less than 24 hours prior to your appointment, a cancellation fee equal to 1/2 the reserved service booked will be charged. No Shows will be charged full price of service booked. Please remember to confirm you appointment when you receive the confirmation request.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof. It is my choice to receive spa treatments, including massage, skin care and body treatments. Because massage/bodywork, skin care and other spa treatment should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, or answered all questions asked of me honestly. I will update Massage & Skin Care By Angela of any changes to my health status. I understand that the aesthetician and massage therapist do not diagnose illnesses, disease, or physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals, or perform spinal manipulation or skeletal adjustments and nothing said in the course of the session given should be construed as such. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that it is recommended I see a primary healthcare provider for that service. If I experience any pain or discomfort during the session, I will immediately inform the massage therapist or aesthetician so that the service may be adjusted to my level of comfort or discontinued. I further understand that I am paying for treatment and not a result and that there will be no returns, refunds or exchanges. Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, DermaFile or DermaDisc treatments, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
Signature
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New Client Intake Form

Your Health

Massage

Skincare

Policy Disclosures & Disclaimers