Client Consent form

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

Date *//

Name *

Date of Birth *//

Address *

Cell Phone: *

Email *

Employer: *

Occupation: *

Does your job require that you work outdoors? *

Referred by:

What would you like to achieve from your treatment today?

Your Skin Care

1. Have you ever had a facial treatment before?

2. Have you ever had a body spa treatment before?

Massage:

Salt glow:

Seaweed wrap:

Moor mud:

Body scrub:

Other

3. Which of the following best describes your skin type? (Please circle one type number) *

Creamy complexion - Always burns easily, never tans
Light Complexion - Always burns, tans slightly
Light/Matte Complexion - Burns moderately, tans gradually
Matte Complexion - Seldom burns, always tans well
Brown Complexion - Rarely burns, deep tan
Black Complexion - Never burns, deeply pigmented

4. Do you have any special skin problems or concerns pertaining to your face or body? *

5. Have you ever had chemical peels, laser or microdermabrasion? *

6. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? *

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

8. Have you used an acne medication?

When?

Which drug?

Soap

Shower Gels

Toner

Body Lotions

Mask

Sunscreen

Eye Product

SPF

Cleanser

Night Moisturizer/Cream

Day Moisturizer

Other

Exfoliator

Makeup Products

Scrubs

9. What skin care products are you currently using? (List brand where known)

10. Have you recently used any self-tanning lotions, creams or treatments?

11. Have you used any of the following hair removal methods in the past six weeks?

Lips

Dehydrated
Cracked/Chapped Lips
Other

13. Have you ever had an allergic reaction to any of the following? *

Please Explain *

16. Have you had any recent tanning bed or sun exposure that changed the color of your skin?

17. Have you experienced Botox, Restylane or Collagen injections? *

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

(Please include the number of the question)

May I call you at your home, work or cell phone number to confirm future appointments? *

May I contact you via mail/email about future promotions and news? *

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. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Client Signature

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.

Client Consent form

Client Consent form

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

Your Skin Care

All Services are By Appointment Only

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