Spa Party Facial Treatment

Thank you for taking the time to fill out this form for the upcoming spa party your attending. We’re looking forward to providing you with the ultimate spa experience. All of the information provided is confidential and will only be shared with the spa party coordinator and the technician performing your service. Your privacy and safety is our utmost concern. Please feel to contact us if you have any questions.

Facial Intake Form

Party Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Medical History
1. Are you currently under the care of a Physician?*
- Yes
- No
If yes, for what?
2. Are you taking any medications?*
- Yes
- No
If yes, please list medication and what its for (Example: Albuterol - Asthma)
3. Are you pregnant?*
- Yes
- No
If yes, how far along? Risk factor (low, med, or high)?
4. Are you on birth control or hormone replacement therapy?*
- Yes
- No
If yes, please list name?
5. Have you ever had an allergic reaction to cosmetics, food, drugs, or flowers?*
- Yes
- No
If yes, please explain?
6. Please check any of the following conditions that you have*
- Asthma
- Anxiety
- Arthritis
- Blood Cots
- Cancer
- Diabetes
- Depression
- Dermatitis
- Eczema
- Epilepsy
- Fibromyalgia
- Heart Attack
- Headaches/Migraines
- 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
If yes, please explain?
Skin Care & Therapy
1. Have you ever had a facial before?*
- Yes
- No
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, please provide last date of service.
7. Do you have any special skin concerns pertaining to your facial treatment?*
- Yes
- No
If yes, please explain
8. Please list the brand and name of your skincare products. (Cleanser, toner, moisturizer, serum, etc)
9. Would you like to be contacted to create a skincare regimen for home use?*
- Yes
- No
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
Comments
This field is for validation purposes and should be left unchanged.

Spa Party Facial Treatment

Facial Intake Form

Medical History

Skin Care & Therapy

Policy & Consent