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Spa Services Consent Form
Skin health questionnaire/History
*
Indicates required field
1. What is the reason for your visit today?
*
2. What special areas of concern do you have?
*
3. Which conditions would you like to improve?
*
Acne scarring
Acne
Age spots
Enlarged Pores
ne lines & wrinkles
Hyperpigmentation
Broken Capillaries
Stretch Marks
Surgical/Facial Scars
Other
If Other, enter more information here
*
4. Have you ever had a facial treatment in the past?
*
Yes
No
If yes, what was your experience?
*
5. How would you describe your skin?
*
Normal
Dry
Oily
Combination
Sensitive
Sun-damaged
6. How would you rate your skin?
*
Always burns, never tans
Always burns easily, tans slightly
Burns moderately – tans gradually
Seldom burn – Always tans well
Rarely burns – Deep tan
Never burns – Deeply pigmented
7. Do you ever experience
*
Flakiness?
Tightness?
Redness?
Excessive oily shine during day?
8. What is your current skin regimen?
*
Soap & Water Only
Cleanser
Toner
Mask
Moisturizer
Exfoliation
Sunblock Every Day
Other
If other, please explain
*
9. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?
*
Yes
No
If yes, what are they?
*
10. Do you blush easily?
*
Yes
No
If yes, what are the contributing factors?
*
Emotions
Foods
Temperature changes
Other
If other, please explain
*
11. Do you
*
Sun bathe?
Use a tanning bed?
How often?
*
12. Have you ever had
*
Peels?
Microdermabbrasion?
Facial surgery?
Cosmetic Surgery?
Botox?
Collagen Injections?
Laser resurfacing?
How recently?
*
13. Are you under treatment for any current skin condition?
*
Yes
No
If yes, what?
*
17. What medications/hormone replacement/vitamins do you presently take?
*
14. Does your skin heal
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Fast?
Scars?
Pigments?
15. Do you bruise easily?
*
Yes
No
16. Do you get sores/blisters (Herpes Zoster/Shingles)?
*
Yes
No
18. Have you ever used
*
Accutane?
Retin-A?
Renova?
Topical Antibiotics?
Differin?
Tazarac?
Hydroquinone?
Alpha Hydroxy Acids?
If yes, when and for how long?
*
19. Any personal or family history of skin cancer?
*
Yes
No
If Yes, provide detail
*
20 How would you describe your overall health?
*
Excellent
Good
Fair
Poor
21. Have you had any of the following, past or present?
*
Acne
Allergies
Eczema
Do you wear contact lenses?
HIV/AIDS
Infections
Please provide details
*
22. Have you ever had a reaction to
*
Cosmetics
Metals
Medication
Food
Fragrance
Airborne particles?
Other
If other, please explain
*
23. For women:
Oral contraceptives?
*
Yes
No
Are you pregnant or trying to get pregnant?
*
Yes
No
Are you taking hormone replacement?
*
Yes
No
Do you experience hormone imbalances?
*
Yes
No
24. For Men:
Do you shave with
*
Electric shaver?
Razor?
Do you experience skin breakouts?
*
Yes
No
Do you have ingrown hair?
*
Yes
No
Emergency Contact
*
Emergency Contact Phone Number
*
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, by the La Vida Salon and Spa Facialist.
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 the esthetician 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. I do not hold the 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.
Name (by entering your name and checking agree below, you consent to the above)
*
First
Last
Email
*
Consent
*
Agree
Disagree
Submit
Home
SERVICES
Luana's Services
Team's Services
Spa Services
>
Scalp Facial
Facial
Make-up
Brow Body & Face
Lashes
Hair Extensions
Appointments
Hair Services Request
Extension Consultation
Spa Services Request
Brow, Body, Face Services Request
Lash Services Request
Education
Shadow Day Request Form
Meet the Team
Become A Part Of Our Team
Blog
