Paparazzi Spa - Esthetics Intake Form for Facials & Body Treatments

  • Esthetics Intake Form

    For Facials and Body Treatments
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of birth*
     - -
  • Conditions you are experiencing today? (Select all that apply)*
  • Which aroma(s) do you prefer? (Select all that apply)*

  • Esthetics Information

  • What kind of skin do you have?*
  • What areas of concern do you have regarding your skin?*
  • Have you been under the care of a dermatologist within the past year?*
  • Have you had any allergic reaction to any of the following?*
  • Do you currently, or have you used in the last 3 momths Retin-A, Renova, AHA's or Retino/Vitamin A derivative products?*
  • Have you recieved Botox, Restylane, or Collagen injections in the last 6 months?*

  • By signing below, you agree to the following:

    I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatements and agree that I do no have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treamtent to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer of any injury or damages incurred due to any misrepresentation of my health history.

  • Today's Date
     - -
  • Should be Empty: