Facials Intake Form

Facials Intake FormAtlantisDaySpa2020-06-15T18:30:54+00:00

Date *

Name *

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone

Email *

Would you like to receive Newsletters and Specials by email?

Birthday *

The following profile should be completed for all clients. This is to correctly evaluate the client’s special needs in both skin care services and home care maintenance. This information is completely confidential and to be used only for this analysis.

Which skin care brand(s) do you usually use?

What particular issues are you presently experiencing with your skin that you would like to address today?

Safety

Are you allergic or / had any adverse reactions to medications? If yes, what type? If not, please type None. *

Are you allergic to Hydroquinone? *

Yes
No
I don't know

Are you allergic or ever had any adverse reactions to cosmetics, foods, clothing, soap, shampoos, hair dye, perfume, or jewellery? If yes, please describe. If not, please type No. *

Are you allergic to Nickel? *

Are you currently taking any medications? If yes, what kind? If not, please type No. *

Have you had any medical/ health problems occur recently. If not, please type None. *

Do you have a Thyroid condition? *

Hypo
Hyper
N/A

Do you have Cancer? *

Lifestyle

Did you go on vacation or holiday recently, where your skin faced a dramatic change? (Sun, snow, wind) If yes, please explain:

Have you recently had any change in your diet, lifestyle or beauty regimen? *

Have you had recent surgery? *

Contraindications

*Please note that the peel procedures can remove self tanning products

I confirm to the best of my knowledge, that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. *

Comment

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