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RhEAL SPA Intake Form
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Email *
Name *
Today's Date *
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Address
Cell Phone *
Date of Birth
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How did you hear about RhEAL Cosmetics?
Are you Pregnant? (if applicable)
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Date of your last period if applicable?
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Please list your allergies/sensitivities if known
Have you recently had any of the following treatments
Have you used any of the following in the past 6 months?
Do you smoke? (marihuana, tobacco, hookah, vape)
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Have you waxed, threaded or done laser hair removal recently to the area we are performing your service on today?
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What is your level of daily activity?
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How many glasses of water do you drink daily?
What is your skin type?
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Your pain tolerance is
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When was the last time you had a facial with extractions? *
Which of the following do you use in your current skincare regimen
 I verify that I will remove my contact lenses if any, as well as any piercings to the face and/or ears, if possible.
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My primary concerns with my skin are *
If I need extra time for extractions during this facial, I am okay going into overtime at a rate of $10/15 mins (Your esthetician will let you know if this is necessary beforehand) *
I testify that I have answered the above to the best of my knowledge and consent to allow RhEAL Cosmetics, LLC to perform my facial. *
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