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About
- FAQ
Services
Dr. Jedynak-Bell
Cherry Payment Plans
Contact

Home
About
- FAQ
Services
Dr. Jedynak-Bell
Cherry Payment Plans
Contact

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Confidential Client Health History

Relax Your Body ~ Rejuvenate Your Mind ~ Renew Your Spirit.

Microdermabrasion Information Sheet - Discover the rejuvenating power of our natural ingredient facials

Today's Date *

Name *

Date of Birth *

Address *

Cell Phone: *

Email *

Emergency Contact *

Phone *

Your Health

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year? *

No
Yes

Explain: *

2) Any recent surgery, including plastic surgery? *

No
Yes

Explain *

3) Any skin cancer, If so, where? *

No
Yes

Explain *

4) Have you had any of these health conditions in the past or present?

Cancer
Hormone imbalance
Systemic disease
High blood pressure
Spinal injury
Thyroid condition
Diabetes
Heart problem
Arthritis
Asthma
Eczema
Epilepsy
Seizure disorder
Fever blisters
Headaches (chronic)
Hepatitis
Herpes
Frequent cold sores
Immune disorders
HIV/AIDS
Lupus
Phlebitis, blood clots, poor circulation
Covid
Keloid scarring
Skin disease/skin lesions
Any active infection

(Please check all that apply and provide additional information in the space provided)

5) What is your stress level?

High
Medium
Low

Do you take any medications that causes thinning skin or dehydration? *

Do you exfoliate your skin on a regular, If so, what products do you use? *

6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?

Yes
No

Describe

7) Have you used any of these products in the last 3 months? *

Yes
No

8) Have you used an acne medication?

Yes
No

When

Which drug?

9) Do you form thick or raised scars from cuts or burns?

Yes
No

10) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? *

Yes
No

Describe:

When?

11) Do you wear contact lenses?

No
Yes

12) Are you sun burned right now? *

No
Yes

13) How frequently are you use a tanning bed?

Infrequently
Frequently
Regularly

14) Are you claustrophobic?

Yes
No

15) Do you suffer from sinus problems?

Yes
No

16) Have you ever had an adverse reaction after using any skin care product?

Dehydrated
Rash
Irritation
Peeling
Sun Sensitivity
Breakout

(Please circle any that apply)

17) Have you ever had an allergic reaction to any of the following?

Cosmetics
Medicine
Food
Fruits & Veggies
Honey
AHAs
Fragrance
Shellfish
Latex
Aspirin
Other

(Please circle any that apply & Explain)

Please Explain *

Please use this space to complete answers where space was insufficient.

(Please include the number of the question)

Checkboxes *

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. By signing this form you consent to the above, we also utilize taking photos of before and after treatments, I understand the images will be a part of my medical record and may be used for purposes of medical teaching, training, or for marketing purposes (website, or social media). We may blur out your eyes, for privacy. By consenting to photographs and/or video images I understand I will not be compensated from any party. If you choose not to have your photo on social media, please consult your esthetician.

Date *

All Services are By Appointment Only

Come, escape the hustle and bustle, and immerse yourself in a world of relaxation and luxury. Book your appointment today and embark on a journey to rejuvenation at our exquisite spa.

Book Now

Relax and Unwind At Our All Natural Boutique Spa!

At Botanical Healing Wellness Spa we offer a broad variety of luxurious soothing spa treatments from facials, body massage, sauna, and other relaxing treatments.

To enhance your treatments spend some time in our jacuzzi, or indulge in a detoxifying Yoni Steam session. Visit our mini resort like spa today, and experience pure bliss with our one on one pampering.

Quick Links

Facials
Massage
Waxing
Body Scrubs & Wraps
Yoni Steam
Micropigmentation
Microneedling

Business Hours

Monday : 9am -9pm
Tuesday : 9am -9pm
Wednesday : 9am -9pm
Thursday : 9am -9pm
Friday : 9am -9pm
Saturday : 9am -9pm
Sunday: 9am - 9pm

Contact Info

5935 N 195th Dr, Litchfield Park, AZ, 85340
By Appointment Only
info@botanicalhealingwellnessspa.com
(623)-248-8258