SPA

Facial Intake Form

All information provided will be kept confidential.

* Required fields

Name*

Birthdate*

Address*

City*

State*

Zip*

Phone*

Email*

Emergency Contact*

Contact Phone*

Please describe your skin:

Oily

Combo

Dry

Other

The following information will be used to help plan safe and effective treatment sessions.
Please answer the questions to the best of your knowledge.

Do you have any allergies?

YESNOIf yes, please list.

Are you taking any medication and or any antibiotics?

YESNOIf yes, please list.

Do you have sensitive skin or a skin condition?

YESNOIf yes, please identify.

Do you have any areas of dermatitis?

YESNOIf yes, please describe.

Are you adverse to any scents or products?

YESNOIf yes, please list.

Have you had any recent skin procedures?

YESNOIf yes, please list.

What do you love about your skin?

What would you change about your skin?

Do you wear contacts?

YESNO

Please confirm the following statement.

If I experience any pain or discomfort during this session, I will immediately inform the esthetician so that the session may be adjusted to my level of comfort. I further understand that esthetics should not be considered as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, or other qualified medical specialist for any mental or physical ailment that I am aware of. Because esthetics should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep True Nature Petit Spa and the Esthetician updated as to any changes in my medical profile and understand that there shall be no liability on True Nature Petit Spa and the esthetician’s part should I fail to do so.

By typing my full name below, I am electronically signing this form and understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Signature of client* (type your full name)

Date* (mm/dd/yyyy)

Signature of Guardian (if under 18 years of age)

Date (mm/dd/yyyy)