Med Spa Facial Intake Form

At Atlantis Day Spa, we are serious about helping you achieve beautiful, healthy, glowing skin! For us to do that, we require some information about your lifestyle and skin conditions. Please take a few moments to fill out our questionnaire so that we may know best how to serve you.

A visual of your skin is our first tool in determining your skins conditions. Please e-mail three head shot photos of yourself. One straight on, the other two from each side of your face.

- Step 1 of 7

Contact Information:

Name *

First

Last

How would you prefer to be contacted? Please provide this here.

How would you prefer to be contacted? *

Contact me via email
Contact me via phone

Email *

Phone *

Signup and receive our Spa Specials & Events newsletters:

Yes, I would like to receive Atlantis Day Spa newsletters.

LIFESTYLE QUESTIONS

How much time do you spend outside? *

How many weeks per year do you vacation in the sun? *

Do you Swim, or Sauna, Hot Tub, or participate in Suntanning Booths? *

Where are you in your hormonal life cycle? *

Do you smoke? *

Do you drink alcohol? *

Do you take Nutritional Supplements? Please list here. *

What does your diet consist of? Please be as honest as possible, no judgement here, only solutions. Please list a typical day

Breakfast *

Lunch *

Dinner *

Snacks *

SKIN DIAGNOSTIC QUESTIONS

What best describes your skin type? *

What are your skin conditions and concerns? *

Dehydration
Tight Surface Skin
Flakiness
Sensitivity
Eczema
Psoriasis
Rosacea
Broken Capillaries
Acne
Large Pores
Blackheads
Scarring
Oily Shine
Milia
Uneven texture
Pigmentation
Melasma
Hyper Pigmentation
Hypo Pigmentation
Lines and wrinkles
Lack of tonicity
None of the above

What is your morning skin care routine? Please explain what products you use and how you use them, step by step. *

What is your evening skin care routine? Please explain what products you use and how you use them, step by step. *

Which Skin Care Brands are you currently using? *

What in spa treatments/facials are you currently receiving? How often? *

What would you like to achieve with your skin? *

Is there anything else you would like us to know about your skin? *

What Skin Care Services are you Interested in? *

Home care products for maintenance
Spa refresh and maintenance facials
Acne care
Spa corrective, age defying facials
Spa advanced, age defying facials

Please check the boxes in the case of contraindications for any Facial Treatments, or if you are using any of these products: *

Heart problems (pacemaker)
Low blood pressure
High blood pressure
Skin Cancer
Circulatory Problems
Digestive problems
Headaches / Migraines
Epilepsy / Seizures
Hay fever
Asthma
Diabetes
Sensitive eyes
Conjuvitis (pink eye)
Wear contact lenses
Skin Disease
Herpes, cold sores or fever blisters
Auto Immune Diseases
Permanent Make-up
Open wounds
Recent Hair removal (48 hours)
Irritated or damaged skin
Used Accutane (within 6 months)
Recent Retin-A use (within 2 weeks)
Topical Glycolic or AHA usage
Recent exfoliation
Recent Fillers
Pregnant or nursing
None of the above

Permanent Make-up, where? *

How long ago was your filler procedure? *

Type of recent filler?

Botox
Injectable Fillers
Laser Treatments
Plastic Surgery

Safety:

Are you allergic to or had any adverse reactions to cosmetics, foods, clothing, soap, shampoo, hair dye, perfume or jewellery? If yes please describe. Enter NA if not. *

Are you allergic to Nickle? *

Are you currently taking any medications? If Yes, please list. Enter NA if none. *

Do you have a thyroid Condition? *

Have you had recent Surgery in the area to be treated? *

*Please note that peels and exfoliating treatments may remove self tanning products

Med Spa Services Intake Form

Please indicate which Med Spa Services you are interested in below:

Chemical Peels
Tripollar Skin Tightening
Micro Needling (Collagen Induction, lines, small imperfections, skin tightening, pigmentation)
Laser Skin Rejuvenation (pigment and vascular relief)
RF Sublative Skin Re-surfacing (re-texturize for lines, wrinkles, scars, uneven textures, skin tightening)
Sublime RF skin tightening
Hair Removal

Please check the box if you have any contraindications for any of the Med Spa Treatments: *

Pacemaker or internal defibrillator
Superficial metal or other implants
Current history of skin cancer, or current condition of any other type of cancer, or pre-malignant moles or skin lesions
History of any kind of cancer
Sever concurrent conditions, such as cardiac disorders
Allergy to nickel (metal used in RF And Laser Treatments)
Allergy or sensitivity to glycerine
Pregnancy or nursing
Impaired Immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications
Diseases which may be stimulated by light at the wavelengths used, such as Systemic Lupus Erythematosus, Porphyria, and Epilepsy
Clients with history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area, may be treated only after a prophylactic regime such as Acyclovir
Poorly controlled endocrine disorders, such as Diabetes, or Polycystic Ovary Syndrome for hair removal
Any active condition in the treatment area, such as sores, psoriasis, eczema or rashes
History of skin disorders such as, Keloid scars, abnormal wound healing, as well as dry, fragile skin
History of bleeding coagulopathies, or use of anticoagulants except for low dose aspirin (baby)
Use of medications, herbs, food supplements, and vitamins known to induce photosensitivity to light exposure at wavelengths used, such as Accutane, within the last 6 months, Tetracyclines or St Johns Wort within the last two weeks
Facial laser resurfacing or deep chemical peel within the last three months
Any surgical procedure in the treatment area within the last three months or before complete healing
Needle epilation, waxing or tweezing within the last six weeks prior to hair removal treatment
Treating over tattoo or permanent makeup
Excessively tanned skin from sun or sunbeds or tanning cremes within the last three weeks
None of the above

Excessively tanned skin from sun or sunbeds or tanning cremes within the last three weeks

Multiple Choice *

Type I (White) - You tend to have very pale, porcelain or ivory tone skin. You always burn in the sun, and you have a naturally reddish undertone. Your eyes are most likely blue, grey or green and you might rock a head of gorgeous blonde or red hair.
Type II (Beige) - You tend to have fair or cream-coloured complexion, often coupled with subtle beige undertones. Your eye and hair colour could fall anywhere along the range of light to dark, and you might have a handful of cute freckles as well. Although you tend to burn in the sun, you are able to tan occasionally.
Type III (Light Brown) - Your skin is ofter described as having a golden, honey-hued tone. Women and men with light olive colouring also fit into this skin type. At the beginning of the summer, you may find that you burn easily, but you can gradually build a sun-kissed glow by the end of the season.
Type IV (Medium Brown) - Your skin is a gorgeous caramel tone, and tans quickly without burning. With Type IV skin, you most likely have dark hair and probably have dark eyes that range from hazel to ebony as well.
Type V (Black Brown) - Your skin tone might range from radiant bronze to a rich brown. Your eyes and hair are dark. You experience sunburns very rarely, and generally tan quickly and easily.
Type V (Black) - Your skin tone falls in the range of deep mahogany to espresso. You also never have sunburns, and tan quickly and deeply during the summer. You also have both dark hair and eyes.

PRE AND POST TREATMENT REQUIREMENTS

Select the treatment you are going to have, please read the Pre & Post Treatment Requirements below:

Tripollar and Sublime
Micro Needling
Laser Skin Rejuvenation
RF Sublative Skin Resurfacing
Laser Hair Removal

Tripollar and Sublime:

No excessive sun exposure 24 hours prior to treatment
Avoid use of exfoliants 24 hours pre and post treatment
Avoid use of Retinols for one-week pre and post treatment
Follow home care regime prescribed by your skin care professional

Micro Needling:

No excessive sun exposure 24 hours prior to treatment
Arrive make-up free for your appointment
Avoid use of Retinol, and AHA’s for 48 hours pre and post treatment
No alcohol consumption 24 hours pre and post treatment
You may take a mild pain reliever such as Tylenol prior to treatment (NO ADVIL OR ASPIRIN)
Your skin care professional will apply numbing crème before your treatment for your comfort
After Treatment, refrain from washing your face, exercise, saunas, hot tubs, sunbeds, and strong sunlight for 24 hours
Do not use SPF for 48 hours post treatment, then it is imperative that you use SPF 30 or more
Avoid touching your skin unnecessarily. Always wash your hands or use gloves before touching treated skin
Use only the Hyaluronic Serum and mask provided to you for 24 hours post treatment
After 24 hours You may splash your face with tepid water and if you still have some Hyaluronic Serum and mask, continue using that and once it is gone, use the collagen Gel Sample provided for you for the next 24 hours
Avoid makeup for 24 hours post treatment
After 24 hours you may use Jane Iredale Mineral make-up if necessary, and may begin with regular cleanser
After 48 hours you may return to normal skin care regime recommended by your skin care professional

Laser Skin Rejuvenation:

No sun exposure for 3 weeks prior to treatment

No alcohol consumption 24 hours pre and post treatment

Arrive make-up free for your appointment

If there is any hair in the treatment area, please Shave prior to treatment (Do not tweeze or wax)

Avoid exfoliation for 24 hours post treatment, may use mild exfoliant after that

Do not pick at or scratch any dark lesions that appear, as this is your pigment rising to the surface which may feel a little crusty. It should slough off naturally

You may continue your regular skin care regime prescribed by your skin care professional post treatment

Avoid use of Retinol, and AHA’s for 1-week pre and post treatment

Be sure to wear SPF everyday post treatment

RF Sublative Skin Resurfacing:

No sun exposure for 3 weeks prior to treatment
No alcohol consumption 24 hours pre and post treatment
Arrive make-up free for your appointment
Do not use serums, moisturizers or self tanning lotions or sprays before treatment
You may take a mild pain reliever such as Tylenol prior to treatment (NO ADVIL OR ASPIRIN)
Your skin care professional will apply numbing crème before your treatment for your comfort
After 24 hours, you may splash your face with tepid water.
Refrain from washing your face, for 72 hours, (no cleansers containing oil)
You may use a cold compress of clean paper towel soaked in 1 Tbsp Vinegar to 1 cup water for 24-48 hours post treatment or until irritated feeling subsides
Avoid exercise, saunas, hot tubs.
Only use the products your skin care professional provides you with, for 72 hours post treatment
You may return to the regular skin care regime your skin care professional has recommended for you after 72 hours
Avoid use of Retinol, and AHA’s for 1-week pre and post treatment, or until your skin care professional recommends it is safe to do so
Avoid make-up for 24-48 hours. The recommended makeup to use is Jane Iredale Dry mineral makeup, post treatment to prevent any adverse reactions
Avoid sunbeds, and strong sunlight for 72 hours post treatment and then use of SPF 30 or more on treated area is imperative

Laser Hair Removal:

No sun exposure for 3 weeks prior to treatment
No alcohol consumption 24 hours pre and post treatment
Do not use deodorant, serums, moisturizers or self tanning lotions or sprays before treatment
You may take a mild pain reliever such as Tylenol prior to treatment (NO ADVIL OR ASPIRIN)
If there is any hair in the treatment area, please shave prior to treatment (Do not tweeze or wax)
Avoid exercise, saunas, hot tubs.
Avoid sunbeds, and strong sunlight for 72 hours post treatment and then use of SPF 30 or more on treated area is imperative
Your following appointment will be scheduled for 6-8 weeks and therefore you must be out of the sun for at least 3 weeks before your scheduled appointment time. If there is an active tan in the treatment area, you skin care professional will re-schedule your appointment.

Thank you for taking the time to fill out your consultation form. We look forward to helping you achieve beautiful, healthy, glowing skin!

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

Name

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Monday	Closed
Tuesday	9:30 am – 8 pm
Wednesday	9:30 am – 8 pm
Thursday	9:30 am – 6 pm
Friday	9:30 am – 6 pm
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