Facial Intake Form

Instructions

Please read carefully and answer to the best of your knowledge. If you have any questions please contact us by online support chat

How did you heard about us? *
Where do you regularly look for new businesses and offers? *
Will you use a Groupon voucher?

You can find it near the bar code

Personal Information

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Health History

1. Do you wear contact lenses?
2. Have you had any surgery?
3. Please check is you are presently experiencing or have experienced any of the following:
4. Do you have any condition that could affect service options, such as arthritis, allergies, diabetes, or other circulation disorders, heart problems, high blood pressure, sensitivity to heat or any cosmetic ingredients, taking any medications such as blood thinners, etc.?
5. Do you have food allergies?
6. Latex allergies?
7. Any other allergies?
8. Are you currently taking any prescription    medications?
9. Are you currently pregnant or undergoing     fertility treatments?
10. Is there anything your technician should       be aware of before your treatment?
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Skin Care History

11. Primary reason for your appointment today
12. How often do you receive facials?
13. How often do you receive body treatments?
14. Have you ever had an adverse reaction to a cosmetic product?
15. Special concerns you have about your skin:
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Home Care

16. Normal skin routine
17. What skin care products are you currently using at home:
18. Do you take nutritional supplements?
19. Do you exercise?
20. Do you have a tendency to scar?
21. Do you feel your skin is sensitive?
22. We want to show you how your skin is improving as you keep getting treatments with us, so we might document your treatment progress with pictures and/or videos:
In consideration for receiving Ananda Spa services, I hereby release, waive, discharge, and covenant not to sue Ananda Spa, it’s owners, officers, agents, servants, and employees from any and all liability, claims, demands, actions, and causes of action related to any loss, damage, or injury that may be sustained by me or property belonging to me, whether caused by negligence or otherwise, while participating in such activity or while on the Ananda Spa premises, and this waiver and release shall bind the members of my family and any current or future spouse or domestic partner if I am alive, as well as my estate, family, heirs, administrators, personal representatives or assigns if I am deceased. I am fully aware of the risks involved and hazards connected with spa treatment, and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in such an activity, whether caused by the negligence or otherwise.
SIGNATURE OF CLIENT
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Thank You

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