Facial Client Intake

Facial, Waxing, Body Treatment Intake Form
Due to COVID-19, we have added a few more questionaires to the form and updated our Policies and Agreement. All clients (new or current) are required to complete this form prior to service. If you developed any sympton after completing this form and before your service, please give us a call to reschedule your appointment. The safety of our clients and staffs are our top priority.
Full Name*

First NameLast Name
Cell Phone*
E-mail*
example@example.com
Birth Date*

MonthDayYear
Occupation
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you ever received a dose of COVID-19 vaccine?

Yes, First DoseYes, Fully vaccinatedNoPrefer not to answer
Reason for Appointment:

RelaxationHyperpigmentationAcneAnti-agingDark CircleDeep Pore CleaningOther
Have you been tested for COVID-19? If yes, please list the date and result. *
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic:*

FeverChillsCoughSore ThroatDiarrhea, digestive upsetNasal, sinus congestionLoss of sense of taste or smellFatigueShortness of breathSudden onset of muscle soreness (not related to a specific activity)Rash or skin Lesions (especially on the feet)None of the aboveOther
Is this your first facial?

YesNo
Are you presently under a physician's care for any current skin condition or other problem?

YesNo
If so, please explain
Do you wear contact lense?

YesNo
Have you used/had a chemical peel or laser recently?

YesNo
Have you used Retin-A or other Vitamin A derivative?

YesNo
If so, when and how long?
Are you exposed to sun on a daily basis?

YesNo
Are you pregnant?

YesNo
Please check if you are affecter by or have any of the following:

AsthmaCardiac problemEczemaEpilepsyFever blistersHeadaches-chronicHepatitisHerpesHigh Blood PressureHysteractomyImmune DisordersLupusMetal bones, pins, or platesPacemakerSinus problemSkin diseasesUrinary or kidney problemOther
Please explain above problems:
(note: Please check out website for facial contraindication https://www.farashe.com/contraindication/ )
List all allergies (lotion/oil/skincare ingredient):*
What products do you use presently?

Cleaning milkTonerScrubMaskSerumCreamEye creamSun ScreenOther
Where did you find us?*

YelpGoogleFacebook/InstagramFriend's referralDirect Mail MarketingOther
Spa Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

COVID19 modified spa policy:

• Please wear face mask when entering the spa. No touch temperature check will be conducted at the door and hand sanitizer will be provided.

• Please contact the spa before entering to confirm if the waiting area is available.

       • Please turn off your cell phone or put on slient mode for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • You will have a consultation with your Esthetician to discuss your session

Client Agreement:

I understand that estheticians are not trained in the diagnosis and treatment of diseases. I confirm that I have consulted a medical doctor for all conditions circled above and have received authorization to have a facial.

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive esthetician services from Farashe The Day Spa.

I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.

I have stated my pertinent medical conditions, and will update the Farashe The Day Spa of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Farashe The Day Spa and my therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the spa policy and client agreement above.
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
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Facial, Waxing, Body Treatment Intake Form