Client Intake Form - Mist Day Spa
Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.
Name *
Email *
Address *
Phone number *
Date of birth *
MM
/
DD
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YYYY
Age *
Emergency contact, name & phone number *
Please list all allergies *
Please list all medications currently being taken *
If you are currently under the care of a physician, please list for what condition(s)
Are you a smoker? *
Are you pregnant? *
Do you have any metal implants in your body? *
Please select any of the following you have been treated for *
Required
How much water do you drink a day? *
How often do you exercise? *
What is your current occupation? *
What is your ethnic background? *
Required
On a scale of 1 to 10 (1= horrible, 10 = fantastic), please rate how you feel about the overall look of your skin? *
Horrible
Fantastic
How often do you wear sunscreen? *
When was your last sunburn? *
How often do you use tanning beds (within the last year)? *
Is your skin (select all that apply): *
Required
What skin care line are you using? *
Describe your daily skin care routine: *
Have you received any of the following facial procedures in the last 6 weeks? *
Required
What is the most important improvement you would like to see in your skin? *
By selecting "Agree" below, you acknowledge that you understand the information you have provided to be true and correct. You also understand that all information stated is strictly confidential and will not be shared outside of this facility due to HIPPA regulations. *
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