Spa for the Soul
SKIN CARE CLIENT INTAKE & CONSENT FORM
Date: ___________________ Date of Birth: _______________ Gender: ( ) Male ( ) Female
Name: __________________________________________
EMail Address:_______________________________
Address: ___________________________________________________________
City: ___________________________________
State: _______________________ Zip Code: _______________________ Home Phone: _____________________
Work/Daytime Phone: ______________________ Cell: ______________________
Referred By: ________________________________________ Emergency Contact: __________________________________
Emergency Contact Phone: __________________________ Contact Information
Ethnic Skin Type: ( ) Caucasian ( ) African-American ( ) Hispanic ( ) Asian ( ) Eastern Indian ( ) American Indian
Please list any health conditions you are experiencing: _________________________________________________________ _____________________________________________________________________________________________________
Have you ever taken or currently taking ( ) Retin A ( ) Accutane Topical or Oral Antibiotics: ( ) Oral ( ) Topical
What is the name of the antibiotic? ________________________________ How often do you exercise? ___________
What is your level of stress? Low 1 2 3 4 5 6 7 8 9 10 High How many hours of sleep to you get per night? _______
How many 8 oz. glasses of water do your drink each day? ___ How much caffeine and/or alcohol do you consume each day? __ Caffeine __ Alcohol
Do you smoke? Yes No Please list all supplements, medications, allergies or recent surgeries:_____________________________________________ ____________________________________________________________________________________________________
How much UV exposure do you get (sun, tanning beds, commuting in car: _________________________________________
Medical Background Do you have any of the following: ( ) Scars ( ) Stretch Marks ( ) Hyper Pigmentation
Do you suffer from: ( ) Acne ( ) Blackheads ( ) Whiteheads ( ) Milia ( ) Oiliness ( ) Rosacea ( ) Dehydration ( ) Eczema ( ) Cellulite ( ) Vein/Circulation Problems ( ) Psoriasis Where: ______________________( ) Other: ________________________
Have you ever received any of the following treatments? ( ) Facial ( ) Microdermabrasion ( ) Laser Surgery ( ) Chemical Peels ( ) Waxing ( ) Lash/Brow Tint ( ) Laser Hair Removal ( ) Vein Treatments
Please select the box that applies to you: ( ) I never tan, always burn ( ) I tan with difficulty, usually burn ( ) Average Tanning, sometimes burn ( ) Easily tan, rarely burn ( ) I never burn
Client Self Assessment CLIENT INFORMED CONSENT TO TREATMENT
I, ___________________________________________
consent to and authorize Spa for the Soul/Nance Jack to perform skin exfoliation, skin waxing, facials, body treatments and other related skin care services.
Services: __________________________________________________________________________
•I have not used a scrub, Retin-A, Retinol A, take home micro-dermabrasion or glycolic peels in the last 72 hours. ______ (Initial)
•The nature and purpose of the treatment has been explained to me, and any questions I may have regarding this procedure has been explained to my satisfaction. _______ (Initial)
•I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. . _______ (Initial)
•I have no allergies to Iodine. (Seaweed) . _______ (Initial)
•I am not Epileptic and do not have heart or circulation problems. . _______ (Initial)
•Possible side effects include, but are not limited to: mild redness, extreme redness, bruising, local swelling, stinging, tenderness, dry skin, flaking, lightening or darkening of the skin, infections, pimples, bumpy appearance, and cold sore. Most side effects are temporary and generally fade within 72 hours. (Chemical Peels) . _______ (Initial)
•If prone to cold sores, see your physician about a prescription for Aycloovair, Zovirax, or take supplements of Olive Leaf, L- Lysine along with Beta Carotene, and Folic Acid daily. . _______ (Initial)
•It is recommended to discontinue use of all AHAʼs, Glycolics, Retin-A, Renova, or any exfoliating products for up to 72 hours post procedure. Using hydrating, soothing, antioxidants for healing and ice for swelling and inflammation reduction. No sun exposure or tanning beds for 72 hours and use at least a SPF 15 sunscreen daily when receiving treatments is recommended. _______ (Initial)
•I agree to adhere to all safety precautions and home skin care program as recommended by Spa for the Soul/Nance Jack . _______ (Initial)
•I am over 18 years of age, or I have a parental consent co-signed below. . ________ (Initial)
•I will call to inform Spa for the Soul/Nance Jack of any complications or concerns I may have as soon as they occur. _______ (Initial)
•I have been off of Accutane for at least 12 months. . ________ (Initial)
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved.
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.
I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility
I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have read and understand the post-treatment home care instructions.
I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or
concerns regarding my treatment or suggested home product/post-treatment care, I will consult Nance Jack immediately.
I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products
I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks.
All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.
do not hold Spa for the Soul/Nance Jack, Esthetician, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure,
which may be affected by the treatment performed today.
Client Name (Signature): ________________________________________________________________ Date: ______________
Consent to Treatment of Minor: By my signature below, I hereby authorize Spa for the Soul/Nance Jack to administer Aesthetic services, to my child or dependent, as she deems necessary.
Signature of Parent or Guardian: __________________________________________________________ Date:_______________