This field is hidden when viewing the formUpload Your PDF Here: Drop files here or Select files Accepted file types: pdf, Max. file size: 1 GB, Max. files: 1. Full Name First Last AddressApt#CityStateZipTelephone (Primary):Telephone (Alternate):E-mail Address: Birthday:Under: 21, 21-30, 31-40, 41-50, 51-60, 60-65, 70+How did you hear about us?1. Have you had any of these health problems in the past or present? Cancer Diabetes Epilepsy Heart problem Hysterectomy Systemic Disease Hormone Imbalance Spinal Injury Thyroid Condition Varicose Veins HIV/AIDS Hepatitis Other 1. Have you had any of these health problems in the past or present?2. What skin care products are you currently using? Cleanser Toner Exfoliation Serum Eye Cream Moisturizer Sunscreen Masque 3. Have you ever had peels, laser, light therapy, microdermabrasion, wax, dermaplane or any other resurfacing treatment? Yes No If yes, which one & when was the last time you had the treatment? Did you have any complications?4. Are you on any prescription skin medication? Yes No If yes, please list them here:5. Are you currently using any products that contain the following ingredients? Glycolic acid Lactic acid Salicylic acid Other Hydroxy Acids Vitamin A derivatives Others (i.e. Retinol)6. What type of massage pressure do you prefer?SoftMediumFirm7. What is your skin care goals? Acne/Deep Cleansing Reduce Pigmentation Anti-Aging Additional notes or instructions:8. If extractions are needed, how many would you like done? None Light Medium Leave to the discretion of my therapist. 9. Have you ever had a reaction to any of the following? Cosmetics Medicine Essential oils Pollen Food Hydroxy acids Sulphur Fragrance Other Others10. List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin, etc. that you take regularly .11. Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last 3 months? Yes No 12. Are you pregnant, trying to become pregnant or lactating? Yes No 13. Do you have metal implants, a pacemaker or body piercing? Yes No 14. Do you have sinus problems? Yes No 15. Do you wear lenses? Yes No 16. Have you ever experienced claustrophobia? Yes No Please read the following information: I agree to the privacy policy.This Intake form is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only to our staff members to qualify assurance and quality control personnel, to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this info to anyone. We, however, contact you with product-related information. I confirm (to my best knowledge) that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment. I also affirm to keep the practitioner updated as to any changes in my medical profile.I understand that the skin care service I receive is provided for the basic purpose of relaxation, skin care, and/or waxing. I understand that some redness/irritation is possible, and to ask my practitioner about follow-up care. If I experience any pain or discomfort during this session, I will immediately inform her. I understand that there shall be no liability on the practitioner’s part should I fail to do so. I do hereby waive, release and forever discharge HOLISTIC WELLNESS SPA Margarita Pinkhasova from any and all responsibility or liability related to my service.Client Full Name: First Date: MM slash DD slash YYYY Client Signature:Photographic Consent: I consent to photographs being taken before, during and after each procedure. I agree to these photos being stored electronically in my case file and will be used only with my written consent for promotional purposes. Client Signature:Date: MM slash DD slash YYYY CAPTCHA
