Skin Therapy/Facial Intake Form

Personal Information
Skin Care History
Have you ever had professional skin care/esthetics treatments?
Have you ever had a chemical peel, laser, microdermabrasion or any resurfacing treatments? Check which ones you have had:
Have you used any of the facial hair removal methods in the past 2 weeks?
If yes, which treatments?
Please indicate concerns regarding your skin:
Do you have or have you had any of the following in the last 14 days?
If yes, please indicate which treatments below:
Please indicate what you use in your daily skin care regimen:
Health Related
Have you been under the care of any physician, dermatologist, or other medical professional within the past year?
Have you ever been treated for: (Check all that apply)
Have you used Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, Lactic Acid AHA, Salicylic Acid, or any Vitamin A/Retinol derivative within the last 3 months?
Are you currently on blood thinners/aspirin?
Do you wear contact lenses?
Have you ever used Accutane?
Have you used products for hyperpigmentation?
Have you ever experienced a reaction to any of the following:

I ____________________________________ understand, have read and completed this questionnaire truthfully.  I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.  I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.  I acknowledge that the practice of skin care including microdermabrasion, waxing, body treatments, chemical peels and various other beauty procedures are not an exact science and no specific guarantees can or has been made concerning the expected results. Some clients experience more change and improvements than others. In virtually all cases, multiple treatments are required to benefit from the desired results.  I also understand that the following risks and hazards may occur in connection with any particular treatment including but not limited to:  Unsatisfactory results, poor healing, discomfort, redness, blistering, nerve damage, scarring infection, change in skin pigmentation, allergic reaction, and increase hair growth.  I understand that response to treatment varies on an individual basis and that specific results are not guaranteed.  Therefore, in consideration for any treatment received, I agree to indemnify, hold harmless and release from any and all liability White Lotus Day Spa as well as any owners, officers, directors, assigns, insurers, independent contractors or employees of the above company for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.  I understand that White Lotus Day Spa staff members have the right to refuse service if any client’s conduct is disruptive or inappropriate.   I understand that if I cancel an appointment less than 24 hours in advance or am late for an appointment I may be charged for the full scheduled session.

*If minor, signature of legal parent or guardian

I agree that inputting my full name above acts as an electronic signature. The information above is accurate.

Thanks for submitting!