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Spa Ritual Health Intake Form Master 2025

Spa Ritual Health Intake Form Master 2025

Let's get all the health and skincare questions out of the way. Please fill this form out asap. In a couple of days before your appt you'll receive another form & that's where you pick your Rituals.  
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    Please Select
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    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    -
    Pick a Date
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    We promise not to spam or sell your information.
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    By entering your emergency contact you are giving Spa Liz and Co. the right to contact this person in case of emergency and giving permission to Spa Liz to share the details of the situation. Please include Full Name, Phone Number & Relationship to you. 
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    Please check all that apply and provide additional information in the section below.
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    Please list if the issue was resolved and/or under control. Examples: Diabetes controlled by insulin. Cold sores, no current outbreak, sun exposure brings them on. 
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    If yes, please explain:
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    If yes, please explain;
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    Please list any meds & OTC from the last year that may impact your facial: OTC, Retinols, Antibiotics, Anti-decongestants, sun-sensitivity labeled medications, acne medications, oral acne medications from the last 3 years
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    If yes, please explain.
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    This may include Cosmetics, Medicine, Food, Animals, Sunscreens, Iodine, Pollen, AHAs, Fragrances, Shellfish, Latex, Drugs, Others. Did you experience a rash, irritation, peeling, sun sensitivity or break out?
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    Sensitivity can include redness, itching, scaliness, and/or rash) *Sensitive skin is something you are born with - it means you are usually prone to redness, eczema, and product irritation.  (Generally, if you have food allergies, you probably have skin allergies leading to sensitivity)
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    Skin Types:

    • Type I Fair skin tones—Always burns, never tans
    • Type II Light skin tones—Burns easily, tans slightly
    • Type III Fair to olive skin tones—Burns moderately, tans moderately
    • Type IV Light brown skin tones—Burns slightly, tans easily
    • Type V Dark brown skin tones—Rarely burns, tans easily
    • Type VI Dark brown to black skin tones—Never burns, tans easily
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    Please give date and exactly was done.
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    High stress can take a toll on the skin especially if its' chronic (this can also lead to breakouts)
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    Your body repairs itself while you sleep. This includes your skin! It's important to arrange 7-9 hours of sleep to optimize your skin's health.
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    Please answer these two questions so we may better address this during your facial is this is a concern.
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    • Never
    • Sporadic (once a month or less)
    • Frequently (I always have one or two)
    • Severe (I have breakouts in more than two-thirds of my face)
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    • Cysts (Large, red and finflamed blemishes)
    • Pustules (Red and inflamed bump but with a visible whitehead on the surface)
    • Whiteheads (Small blemishes that are white in color)
    • Papules (Red and inflamed bump with the absence of witehead onthe surface)
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    Check all that apply
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    Spa Liz & Co. Policies:

    • All appts are confirmed with a credit card on file.
    • Failure to submit a Health Intake Form within 72 hrs after booking may result in cancellation of the appointment.
    • Forms can be found on the service and scheduling page.
    • As a courtesy, we do try to send forms via SMS. However, if you don’t receive one, please go www.spalizandco.com/scheduling to fill it out.
    • It is up to the client to fill out the form(s) correctly and completely. Policies are still enforced even if forms are not completed and returned.
    • 24-hour notice of cancellation is required before your appointment.
    • If an appointment is canceled within 24-hours, 50% of the total service fees will be charged to the credit card on file, or an invoice will be sent before another appointment can be made. 
    • Failure to give 24-hour notice or a No Show/No Call will result in 100% of the service fees being charged to the credit card on file or invoice sent before another appointment can be made.
    • If late for an appointment (varies depending on appointment length), it will still end on time, or the appointment will be canceled and full payment required.
    • All packages expire one year from the purchase date unless otherwise noted.
    • All sales are final on products, services, and packages. Therefore, they are non-transferable, non-refundable, and cannot be substituted.
    • No one besides who the appointment is for is allowed in the spa. You will be asked to reschedule and pay the service cancellation fee if the accompanying person can not wait outside.
    • Minors receiving service must have a legal custodian/parent. Please see FAQ for more information regarding minors.
    • If you have any questions or concerns, please go to the F.A.Q. page found under the Home section at www.SpaLizandCo.com.

    Consent to Treatment:

    • I have had any questions or concerns answered before treatment today.
    • I will address any future questions with my skin therapist before treatment.
    • I give permission to my therapist to perform the facial treatment we have discussed and will hold her and her company harmless from any liability that may result from this treatment.
    • I have given an accurate account of the questions asked above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically.
    • I understand my aesthetician will take every precaution to minimize or eliminate adverse reactions as much as possible.
    • I am willing to follow recommendations made by my aesthetician for a home care regimen that can minimize or eliminate possible adverse reactions.
    • If I have additional questions or concerns regarding my treatment or suggested home products / post-treatment care, I will consult the aesthetician immediately.
    • I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.
    • I certify that I have read and fully understand the above paragraphs and have had sufficient opportunity for discussion to answer any questions. I understand the procedure and accept the risks.
    • I do not hold the aesthetician responsible for any of my conditions that were present but have not disclosed the time of this skincare procedure, which may be affected by the treatment performed today.
    • I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure have been explained to me, along with the risks and hazards involved.
    • Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.
    • I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.
    • I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.
    • I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.

     

     

    3/2/2022

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    I understand and agree to the Consent of Treatment, and Spa Liz Polices by signing below.
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