Intake Form

Please fill out the following form.

First Name

Email Address

Last Name

Date of Birth

Have you ever had a facial before?

Yes

Are you currently pregnant?

Yes

About how much water do you drink daily?

Do you smoke?

Yes

How much exposure to the sun do you get?

Light

Moderate

Excessive

Do you have any food or drug allergies?

Yes

Please list any allergies

Do you take medication for any skin condition ?

Yes

List medications

Are you currently using any products that contain glycolic acid, lactic acid, alpha hydroxy acids, retinol, or prescription creams?

Yes

if yes to previous question, please list below

Please list all products in your current home regimen.

Please list your treatment goals.

Waiver

In consideration for receiving services at the "Spa", I hereby release, waive, discharge, and covenant not to sue the Spa from any and all liability, claims, demands, actions, and causes of action related to any loss, damage, or injury that may be sustained by me or property belonging to me, whether caused by negligence or otherwise on the Spa premises. I am fully aware of the risks involved in the services which may be rendered, which may include, but are not limited to: allergic reaction, scarring, numbness, tingling/pain, etc. and hazards connected with skin care treatments. I voluntarily assume full responsibility for any risk of loss, property damage, and personal injury, that may be sustained by me, or any loss or damage to property owned by me, whether or not caused by negligence or otherwise.

Your Signature

Select a date

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