Moana Beauty Spa Intake Questionnaire for Skin Rejuvenation and Aesthetic Concerns
Please complete this form before your appointment so we can personalize your treatment safely and effectively.
Client Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Treatment Interests
Date of Appointment
*
-
Month
-
Day
Year
Date
What concerns would you like to address?
*
Wrinkles / fine lines
Pigmentation / sun damage
Skin laxity / lifting
Acne / acne scars
Texture / pores
Redness
Dullness
Other
Have you had this type of treatment before?
*
Yes
No
Medical / Skin History
Are you pregnant or breastfeeding?
*
No
Yes
Do you have any allergies? If yes, please list
Do you have any skin conditions, sensitivities, or history of hyperpigmentation or keloid scarring? If yes, please explain
Are you using Retin-A / retinoids, Accutane / isotretinoin, hydroquinone, antibiotics, steroids, or other prescription skincare or medications? If yes, please list
Have you had Botox, filler, chemical peels, microneedling, laser, RF, or other facial treatments in the last 4 weeks? If yes, please explain
Do you have any major medical conditions we should know about?
Heart condition
Diabetes
Epilepsy
High blood pressure
Cancer history
Thyroid condition
Autoimmune condition
Contagious illness
None of the above
Consent
Consent and Acknowledgments
*
I confirm that the information I provided is accurate and complete.
I understand results vary and are not guaranteed.
I understand treatments may cause temporary redness, irritation, peeling, swelling, bruising, sensitivity, purging, hyperpigmentation, or other unexpected reactions.
I had the opportunity to ask questions and voluntarily consent to evaluation and treatment.
Photo Consent
I consent to Moana Beauty Spa taking before-and-after photos and/or treatment-area photos for treatment documentation, progress tracking, client records, and internal training purposes. I understand these photos will be kept private and will not be posted or used for marketing, social media, advertising, or public display without my separate written permission.
Do you consent to photo documentation?
*
Yes
No
Photo consent notes or limitations
Signature
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Optional clinical photography consent
I consent to clinical photos for internal documentation and treatment progress tracking only.
Optional consent to use my before/after photos for marketing, social media, website, and promotional purposes.
YES, I Consent.
NO, Do Not Use My Images For Marketing Purposes
Submit
Submit
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