Facials Intake Form - ASP-MEDIEN.DE

Contact Info

Name *

Email: *

Address: *

Phone *

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Client History

Have you had any facial treatment in the past? *YesNo

When was your last facial waxing treatment? *

Do you have any allergies? *YesNo

If yes, please list *

Have you ever seen a dermatologist? *YesNo

What skin conditions have been medically diagnosed? *

Have you taken Accutane in the last year? *YesNo

Are you currently using any medicated facial ointments or creams? *YesNo

If yes, please list *

Do you get Botox and/or fillers? *YesNo

If yes, when was your last treatment? *

Do you suffer from any medical conditions, current or past? *YesNo

If yes, please list *

Do you have high blood pressure? *YesNo

Do you have any metal face and/or body implants? *YesNo

Have you ever had any face and/or body surgeries (including plastic surgery)? *YesNo

If Yes, Please Describe: *

Do you use retinoids/retinol? *YesNo

Have you ever had a chemical peel? *YesNo

If yes, when was your last peel? *

Have you ever had facial laser hair removal or laser resurfacing? *YesNo

If yes, when was your last treatment? *

What skincare products are you using at home? *

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Client Certification and Consent

Date Signed *

Certify *YES, by my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge. By signing this form, I consent to receive treatment from the Palm Tree Day Spa.

Client Signature *

Save Info & Finish Later

Intake Form – ( Facials )

Confidential Skin Health Questionnaire

Contact Info

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Client History

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Client Certification and Consent