Renewed Spirit Day Spa
Facial Intake Form
Description
Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone *
Your answer
Email *
Your answer
Birthday *
MM
/
DD
/
YYYY
Is this intake for a minor *
Emergency Contact Info- Name and Phone
Your answer
Would you like to receive updates on important information, promotions and available appointments? You can unsubscribe at anytime. *
Required
Are you currently under medical supervision?
Are you currently taking any medications? Please list.
Your answer
Do you currently or have you ever had any of the following
What would you like to achieve today from your service
Your answer
Have you ever had a professional facial treatment before? If so, how long ago?
Your answer
Which of the following describes your skin type? (Please choose one option)
Do you have any special skin problems or concerns pertaining to your skin, please specify.
Your answer
Have you ever had chemical peels, laser or microdermabrasion? Is so, how long ago?
Your answer
Do you use Retin-A, Renova, Adapalen Hydroxyl Acid or Retinol/Vitamin A derivative products? Please describe.
Your answer
Are you currently using any skin products at home? Please check all that apply.
What areas of concern do you have regarding your skin. Please check all that apply.
Please list any allergies or sensitivities
Your answer
Do you smoke?
Are you pregnant?
Do you consent to photos during treatment? Photos are used to show before and afters of skin/treatment and may be used in forms of media and on website, however your privacy is important and your information/identity will be withheld.
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