You can always press Enter⏎ to continue
ECLAT SKIN DISCOVERY & CONSENT
Please complete this form at least 24 hours before your scheduled appointment
32
Questions
START
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
3
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
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
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
Please Select
Please Select
United States
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
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
Country
Previous
Next
Submit
Press
Enter
4
Please provide us with a phone number for your appointment confirmations and follow ups:
*
This field is required.
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
5
Date of Birth
*
This field is required.
-
Date
Year
Month
Day
Previous
Next
Submit
Press
Enter
6
In Case of Emergency, please notify: (Name and phone number)
*
This field is required.
Previous
Next
Submit
Press
Enter
7
Please let us know how you heard about us!
*
This field is required.
Google
Facebook
Instagram
Yelp
Referral
Other
Previous
Next
Submit
Press
Enter
8
Take advantage of the ECLAT Referral Program! New Clients: Please list the person who referred you and you both will receive a $25 spa credit
Previous
Next
Submit
Press
Enter
9
GENERAL HEALTH HISTORY: Please check if you currently or previously had a history with any of the following. (N/A for none)
*
This field is required.
Autoimmune Deficiency
Epilepsy or Neurological Problems
Heart Disease or Pacemaker
Allergies / Asthma
HIV/ AIDS / Hepatitus
Bleeding or Clotting Disorder
Skin Allergies or Sensitivities
Herpes Simplex / Cold Sores
Keloid Scar Formation
Diabetes
Pregnant or Nursing
Skin Cancer
PCOS or Hormone Imbalance
Rashes, warts
History of COVID / COVID Vaccine
None
Other
Previous
Next
Submit
Press
Enter
10
Answers to Health History (N/A for none)
*
This field is required.
Previous
Next
Submit
Press
Enter
11
What is your Cosmetic History? (Past and present)
*
This field is required.
Facial Surgery
Botox or Filler
Facial Laser Treatment
Microneedling
Permanent Makeup
Chemical Peels
Facial Waxing
Tanning
Accutane Usage
Acne Prescriptions
Use of Retinol / Retin A
Sensitive to Lidocaine
Weight Loss Shots
N/A
Previous
Next
Submit
Press
Enter
12
Answers to Cosmetic Health History (N/A for none)
*
This field is required.
Previous
Next
Submit
Press
Enter
13
Are you currently taking any medications or supplements?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
14
List ALL medications and supplements currently used: (N/A for none)
*
This field is required.
Previous
Next
Submit
Press
Enter
15
Are you currently using, or previously used any injectable semaglutide or tirzepatide medications? (Ozempic, Mounjaro, Wegovy, Rybelsus etc)
*
This field is required.
**Use of these weight loss injections causes skin changes and inflammation which may increase chances of side effects from some aesthetic treatments. Please always notify your provider when you are using these medications. **
YES
NO
Previous
Next
Submit
Press
Enter
16
FEMALES ONLY: Are you taking birth control, pregnant, breastfeeding, trying to become pregnant or using hormone replacement therapy (HRT)?
*
This field is required.
I am taking birth control
I use hormone replacement (HRT)
I am trying to become pregnant
I am pregnant/ breastfeeding
N/A
Previous
Next
Submit
Press
Enter
17
Contacts should not be worn during a facial. Do you wear contacts?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
18
What can we help you with?
*
This field is required.
ACNE/ SCARRING
LOSS OF FIRMNESS
SUN DAMAGE/ SPOTS
SKIN TEXTURE / PORES
WRINKLES
CREPY SKIN
SENSITIVE SKIN / ROSACEA
DRY SKIN
THINNING HAIR
UNWANTED FAT
STRESS
MASSAGE
Previous
Next
Submit
Press
Enter
19
What services are you interested in? (check all that apply)
*
This field is required.
Glacial Cryo Facial
Cryo 360 Body Contouring
Mindful Facials
ProCell Microchanneling
Microneedling Facials
MiraPeel HydraFractional
Dermaplane
Airbrush Infusion Facial
DMK Enzyme Treatment
DMK MD StemZyme Series
HydraGlow Facial
Acne Facials (see below)
Pregnancy Friendly Treatments
Sensitive Skin Facials
Back Facial / Peel
Brow Waxing & Tinting
Lash Lifts & Extensions
Student Model
Full Body Massage (Coming soon!)
Scalp Spa Treatments
PMU Powder Brows
PMU Lip Blushing
Consult for DMK Products
Consult for Face Reality Products
Previous
Next
Submit
Press
Enter
20
ACNE CLIENTS: Please check any of the following which apply to you (N/A for all other clients)
*
This field is required.
Previous
Next
Submit
Press
Enter
21
FITZPATRICK CLASSIFICATION
>> INDICATE YOUR SKIN TYPE ON THE NEXT SLIDE
Previous
Next
Submit
Press
Enter
22
WHICH SKIN TYPE ARE YOU?
*
This field is required.
TYPE I - Always burns, never tans. Red or blonde hair, light eyes.
TYPE II - Burns easily, tans minimally. Blond hair, light eyes.
TYPE III - Sometimes burns, tans gradually. Brown hair, blue/hazel eyes.
TYPE IV - Rarely burns, always tans, olive complexion. Brown hair, brown eyes. Often of Native American, Asian, Hispanic, and Mediterranean descent.
TYPE V - Rarely burns, tans profusely. Often of African American, Hispanic, Asians, Arabic, Pacific Islander or East Indian descent.
TYPE VI - Never burns, tans profusely and deeply. African American or South Pacific Islander.
Previous
Next
Submit
Press
Enter
23
I understand before and after photos are required for all Cryo slimming treatments, permanent make-up and student models.
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
24
I'd like my esthetician to know the following lifestyle information (select all that apply):
*
This field is required.
Previous
Next
Submit
Press
Enter
25
What type of skin care routine are you looking for?
*
This field is required.
Previous
Next
Submit
Press
Enter
26
Current Skincare:
I understand using OTC brands or mixing brands may cause adverse reactions. Please list ALL skin care products currently being used or write N/A for none.
Previous
Next
Submit
Press
Enter
27
I spend most of my SKINCARE budget on:
*
This field is required.
Previous
Next
Submit
Press
Enter
28
Have we left anything out? Tell us in your own words what you are looking for and how we can best serve you:
(OPTIONAL)
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
29
Booking and Cancellation Policy
*
This field is required.
By booking an appointment with ÉCLAT Skin Confidence Spa , you confirm you have reviewed and agree to the scheduling and cancellation policies posted on our booking page. Cancellation/rescheduling less than 24 hours before your appointment may result in charges of up to 50% of the cost of the scheduled service. No-shows are charged 100% of the service.
YES
NO
Previous
Next
Submit
Press
Enter
30
Post Care
I understand my skin may be sensitive after treatment. If I experience skin irritation, itching or any other skin changes I agree to contact ÉCLAT Skin Confidence Spa immediately at (704) 890-1071. I understand any delay in doing so could impair the results of the treatment or damage my skin. I have reviewed the post care and consents for my specific treatment and agree to adhere to all post treatment recommendations.
YES
NO
Previous
Next
Submit
Press
Enter
31
Treatment Consent
*
This field is required.
This procedure is elective and I authorize ÉCLAT Skin Confidence Spa to perform facials which may include one or more of the following services: microdermabrasion, dermaplaning, hydrafacial, scalp treatments, chemical peel, radio frequency, microcurrent, cryoskin, mesostamping, DMK enzyme therapy, extractions, DPL and LED light therapy, waxing, massage. Some skincare products contain adipose stem cells or active ingredients which may cause allergic reactions. I have given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I have read and fully understand this consent and all information detailed above and accept the risks. All questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected
YES
NO
Previous
Next
Submit
Press
Enter
32
By signing below I understand esthetic services are not intended as medical treatment. I have advised my esthetician of all health issues being treated by a physician and all medications I am taking and agree to update that information if my health or medications change in the future. *I understand I will be required to check-on online 24-hours in advance before each spa appointment.
*
This field is required.
Clear
Previous
Next
Submit
Press
Enter
33
How was your experience using this electronic Health History form?
*
This field is required.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Previous
Next
Submit
Press
Enter
34
CLICK ON SUBMIT TO COMPLETE! Contact us at (704) 890-1071 with any problems or questions.
Previous
Next
Submit
Press
Enter
35
Tags
Todo
In Progress
Done
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
35
See All
Go Back
Submit