Renewed Spirit Day Spa
Facial Intake Form
Is this intake for a minor
Emergency Contact Info- Name and Phone
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Are you currently under medical supervision?
Are you currently taking any medications? Please list.
Do you currently or have you ever had any of the following
Carpal Tunnel Syndrom
Contagious Skin Condition
Neurological disorders (MS, Parkinson's, Chronic Pain)
Open sores or wounds
Stroke, heart attack
High/ low blood pressure
Sensitive to touch /pressure
Dizziness, ringing in the ears
What would you like to achieve today from your service
Have you ever had a professional facial treatment before? If so, how long ago?
Which of the following describes your skin type? (Please choose one option)
I -Creamy Complexion- Always burns easily, never tans
II-Light Complexion- Always burns, tans slightly
III- Light/Matte Complexion- Burns moderately, tans gradually
IV- Matte Complexion- Seldom burns, always tans
V- Brown Complexion- Rarely burns, deep tan
VI- Dark Brown- Rarely burns- Deeply pigmented
Do you have any special skin problems or concerns pertaining to your skin, please specify.
Have you ever had chemical peels, laser or microdermabrasion? Is so, how long ago?
Do you use Retin-A, Renova, Adapalen Hydroxyl Acid or Retinol/Vitamin A derivative products? Please describe.
Are you currently using any skin products at home? Please check all that apply.
Exfoliants (scrubs, brushes)
Serums, eye creams
What areas of concern do you have regarding your skin. Please check all that apply.
Sun spots/brown spots
Uneven skin tones
Please list any allergies or sensitivities
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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