Name:* First Last Date* Date Format: MM slash DD slash YYYY Name First Last (if under 18 years of age)Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone:*Emergency Contact Phone:*Email:* Please check current skin care products you use:* Facial Scrub Cleansing Cream Skin Toner/ Astringent Soap Eye Make-Up Remover Day Cream Exfoliants Eye Cream Night Cream Mask Body Lotion / Cream Body Scrub OtherIf other, please list:How do you find your skin?* Normal Dry Oily Combination Sensitive / Breakout Acne Very Sensitive / Rosacea MatureAre you currently using any products that contain the following ingredients?* Glycolic Acid Actic Acid Any Exfoliating Scrubs Any Hydroxy Acid Product Vitamin A Derivaties (i.e. Retinol) Retin-A RenovaDo you have any tendencies to any of the following?* Ingrown Hair Hyperpigmentation Scarring Bruising Bumps / Hives RednessHave you recently received any of the following treatment?* Microdermabrasion Chemical Peel Lash Tint Brow Tint Micro Needling Facial Waxing Laser ResurfacingIf yes please specify the date you received your last treatmentDate of Microdermabrasion: Date Format: MM slash DD slash YYYY Date of Chemical Peel: Date Format: MM slash DD slash YYYY Date of Lash Tint: Date Format: MM slash DD slash YYYY Date of Brow Tint: Date Format: MM slash DD slash YYYY Date of Micro Needling: Date Format: MM slash DD slash YYYY Date of Facial Waxing: Date Format: MM slash DD slash YYYY Date of Laser Resurfacing: Date Format: MM slash DD slash YYYY Have you ever had a reaction to any of the following?* Cosmetics Medicine Fragrance Pollen Food Hydroxy Acids Animals Sunscreens OtherIf other, please list:Have you ever had a facial treatment before?*YesNoIf yes, when was that?What are your main concerns?* Acne Scars Wrinkles/Fine Lines Age Spots Acne Scarring Enlarged Pores Deep wrinkles Uneven skin tone Aging Hyperpigmentation Dark eye circles Blackheads/whiteheads Dull/dry skin Dehydrated Sun damage RpsaceaWhat would you like to achieve from your treatment today?*Do you have any special skin problems or concerns pertaining to your face or body?*YesNoIf yes, please specifyHave you experienced Botox, Restylane or Collagen injections?*YesNoIf yes, please specify:Do you ever experience these conditions on your skin?* Flakiness Tightness Obvious Dryness*What SPF do you use on your face?How often/when? This information is to ensure we carry out the appropriate treatments for you, taking into consideration any medical conditions which might have treatment contraindications.* Female clients onlyPlease indicate any of the following that apply to you:* Pregnancy* Menopause Heart Condition High Blood Pressure Rosacea Eczema Asthma Varicose Veins Water Retention Breast Feeding* Diabetes Epilepsy Psoriasis Dermatitis Skin CancerAny other medical conditions?*YesNoIf yes, please provide more information.Are you taking any medications?*YesNoIf yes, please provide the names of the medications.Do you suffer from any allergies?*YesNoIf yes, please provide information about your allergies.Do you smoke?*YesNoAre you healing impaired?*YesNoDo you follow a restricted diet?*YesNoWithin the last nine months, have you undergone any surgery?*YesNoWithin the last year, have you been under a dermatologist or other physician’s care?*YesNoHow would you describe your stress levels from 1- 10*Please enter a number from 1 to 10.(1=Iow, 10=high):How frequently do you exercise:*Everyday3 Times A WeekOnce A WeekIrregularlyDescribe your own exercise:How much plain water do you consume daily?*None1-23-56-10Over 10Male Clients OnlyWhat is your current shaving system?*ElectricWet ShaveDo you experience irritation from shaving?*YesNoDo you experience ingrown hairs?*YesNoAny other information?* I acknowledge that side effects can occur and I fully accept the risk. I understand that my Esthetician, will take every precaution to minimize or eliminate negative reactions as much as possible. I will consult my Esthetician first should I have any complications after receiving my treatment. I have been given the opportunity to ask questions and any questions have been answered to my satisfaction.* I have read the information and recorded my medical history accurately with all pertinent information. For future services, I agree to inform my spa technician of any changes in my medical status and/or the above information. I understand spa services are not to be considered medical treatment, and as such, the spa technician cannot prescribe treatment of pharmaceuticals.* I confirm that the information given above is correct, and that to my knowledge, I have not withheld any information that may be deemed relevant to the treatment I am receiving. I acknowledge that there are potential risks and complications to receiving any procedure, and I take responsibility for any side effects should they occur. I consent to the facial & skin treatment with the understanding that it is an elective procedure, no medical claims are expressed.