Facial Treatment

Thank you for taking the time to fill out this form for the upcoming treatment. We’re looking forward to providing you with the ultimate spa experience.

All of the information provided is confidential and used by the esthetician performing your service to customize and create the best service and experience for you.

Your privacy and safety is our utmost concern. Please feel to contact us if you have any questions.

Client Intake Form

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Age
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Emergency Contact*
First Last
Phone*
Occupation*
Medical History
1. Are you currently under the care of a Physician?*
- Yes
- No
If yes, for what?
2. Are you taking any medications? (please exclude birth-control from your response)*
- Yes
- No
If yes, please list medication and condition (Example: Albuterol - Asthma)
3. Do you smoke?*
- Yes
- No
If yes, how many per day?
4. Have you had skin cancer?*
- Yes
- No
If yes, please list type and body location
5. Are you currently receiving radiation for this diagnosis?*
- Yes
- No
- N/A
If yes, please list last treatment date
6. Please check any of the following conditions that you have*
- Asthma
- Anxiety
- Arthritis
- Blood Cots
- Cancer (other than Skin Cancer)
- Diabetes
- Depression
- Dermatitis
- Eczema
- Epilepsy
- Fibromyalgia
- Heart Attack
- Headaches/Migraines
- Hepatitis
- Herpes
- Hysterectomy
- Immune Disorder
- Infectious Disease (i.e. HIV)
- Joint Replacement
- Kidney Dysfunction
- High Blood Pressure
- Low Blood Pressure
- Lupus
- Neuropathy
- Numbness
- Skin Disease/Disorder
- Stroke
- Sprain/Strain
- Sinus Problems
- N/A
Please explain any of the the items checked above
7. Have you had an allergic reaction or sensitivity to the following:*
- Almonds
- Aloe Vera
- Apples
- Aspirin
- Cosmetics
- Citrus
- Flowers
- Hydroquinone
- Latex
- Milk
- Shellfish
- Other
- N/A
Please explain any of the the items checked above
8. Please check any supplements that you are taking orally*
- Biotin
- Collagen
- Diuretics
- Dong Quai
- Essential Oils
- Hyaluronic Acid
- St. John's Wort
- Vitamins
- N/A
Please explain any of the the items checked above
9. Are now using or have ever used Accutane?*
- Yes
- No
If yes, please provide last date of treatment
10. Have you visited a dermatologist recently?*
- Yes
- No
If yes, please advise of reason
11. Have you had any recent surgery, including plastic surgery?*
- Yes
- No
If yes, what type?
12. Have you had any body piercings, tattoos or permanent cosmetics within the last year?*
- Yes
- No
If yes, what type?
Female Clients
1. Are you on birth control?*
- Yes
- No
If yes, what type?
2. Are you pregnant?*
- Yes
- No
4. Are you breast feeding?*
- Yes
- No
If yes, how far along? What is your risk factor (high, med, low)?
3. Are you trying to get pregnant?*
- Yes
- No
5. Any recent changes with your hormones?*
- Yes
- No
If yes, what type?
6. Are you in menopause?*
- Yes
- No
If yes, what phase?
7. Are you on/taking hormone replacement therapy?*
- Yes
- No
If yes, what type?
Skin Care & Therapy
1. Have you ever had a facial before?*
- Yes
- No
If no, when was your last facial?
2. Which of the following best describes your skin type? (please choose one)*
- Creamy complexion - Always burns, never tans
- Light complexion - Always burns, sometimes tans
- Light/Matte complexion - Sometimes burns, always tans
- Matte complexion - Rarely burns, always tans
- Brown complexion - Rarely burns, deep tan
- Dark complexion - Never burns, deeply pigmented
3. Which best describes your skin type? (please choose one)*
- Normal
- Dry
- Oily
- Combination
- Sensitive
- Rosacea
4. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
- Yes
- No
If yes, please provide last date used.
5. Have you ever had chemical peels, laser or microdermabrasion?*
- Yes
- No
If yes, please provide last date of service.
6. Have you experienced Botox, Restylane or Collagen injections?*
- Yes
- No
If yes, which service and last date of service.
7. Please select any of the following you use in your skincare routine:*
- Cleanser
- Toner
- Serum
- Day Moisturizer
- Sunscreen
- Night Moisturizer
- Eye Cream
- Weekly Mask
- Exfoliator
- Anti-aging/Treatment serum
8. Please list the brand and name of your skincare products that you selected from the list above. (Cleanser, toner, moisturizer, serum, etc)*
9. Are you open to changing these?*
- Yes
- No
10. Please select any of the following you use in your skincare routine:*
- Overwhelmed with what to use?
- Not sure what type of products to use
- Too many steps to keep up with
- Not enough time
- Other
If "other" was selected, please explain
11. Do you have any special skin concerns pertaining to today's treatment?*
- Age Management
- Hydration
- Break-Outs
- Acne Scars
- Dull Skin
- Fine Lines
- Large Pores
- Hyperpigmentation
- Other
please specify:
12. What is your skincare goal?*
- Improve
- Maintain
- Prevent
- None
13. How often would you like to receive facials?*
14. Are you presently using (or used in the past) Azlex, Differin, Retin-A, Renova, Tazarac, Retinol/vitamin A derivative products Glycolic or Alpha Hydroxyl Acids?*
- Yes
- No
If yes, how long?
15. Have you ever had any of the following treatments?*
- Botox
- Chemical Peels
- Collagen Injections
- Derma planning
- Facial Waxing/Threading
- Laser Hair Removal
- Laser Resurfacing
- Microdermabrasion
- Micro needling/Collagen Induction Treatment
- Nano-Infusion
- None
If yes, please specify treatment and date
Lifestyle
1. Do you often experience stress?*
- Yes
- No
If yes, please explain
2. Do you use a tanning bed?*
- Yes
- No
If yes, please specify treatment and date
3. Have you recently had a sunburned/wind burned face?*
- Yes
- No
4. How many hours do you spend outdoors?*
5. Do you work out?*
- Yes
- No
If yes, please specify type and frequency
6. What is your diet like?*
- Vegan
- Vegetarian
- Pescatarian
- No/Low Carbs
- High Protein
- No/Low Sugar
- Laser Resurfacing
- I don't follow anything specific
- Other
If other, please explain
5. Do you consume alcohol?*
- Yes
- No
- N/A - I don't consume alcohol
How many each week?*
6. How many hours of sleep do you get each night?*
Policy & Consent
Slight redness due to stimulation is normal following skincare treatments and should go away within a few hours at the most. If breakouts occur, it is more than likely due to trapped dirt and oil that is coming to the surface. If cared for properly, using a regular cleansing and moisturizing regimen with quality products recommended by a licensed esthetician or dermatologist, breakouts should disperse within a few days. If breakouts continue after a skincare treatment and proper home skincare regimen, you may be sensitive to the product being used. Consult the Synergy Skin Care Spa, LLC immediately if problems occur. Be sure to ask the technician if you have any questions or concerns related to the treatments or post-treatment care. Due to the high-risk nature of some medical conditions, it may be necessary to obtain a doctor’s release or permission before receiving treatment. I agree to inform the therapist of any experience of pain or concerns before, during and/or after the treatment. I further understand that services provided are NOT a substitution for a medical examination, diagnosis or treatment by a medical or chiropractic physician or other healthcare specialist.
Informed Consent*
- I understand that this is a cosmetic treatment and that no claims are expressed or implied.
- I understand that to achieve maximum results, I may need more than one treatment and I need to follow the maintenance home protocol.
- I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking, and climate.
- I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Synergy Skin Care & Spa.
- I have revealed any medical condition that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels or surgery, types of contraindicated medications such as Accutane, hormone replacement therapy or use of Retin-A.
- I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by Synergy Skin Care & Spa and its authorized representatives.
Photography Policy*
I agree to the photography policy.
I give permission for photographs to be used by Synergy Skin Care & Spa for educational and/or promotional purposes. Complete client confidentiality will be maintained at all times.
Name*
First Last
I have read and fully understand the terms within the above policies and consent. All my questions have been addressed to my satisfaction. I certify that all of the above information is true and to the best of my knowledge. I understand and agree with the policies. By signing this form, I waive any and all claims, damages, action and liabilities against Synergy Skin Care & Spa arising out of or relating to massage therapy, hand/foot treatments, skincare and allergic reactions to services performed. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I am eighteen years of age (18) or older.
Date*
Date Format: MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Facial Treatment

Client Intake Form

Medical History

Female Clients

Skin Care & Therapy

Lifestyle

Policy & Consent