Facial Treatment Form - Beverly Hills Day Spa

PERSONAL INFORMATION

Name *

First

Last Name

Last

Date of Birth

Phone

Email *

May we add you to our e-mail list?

Yes

No, thank you

HEALTH INFORMATION

(Please select all that apply)

Are you pregnant?

No

Yes

Women only

Are you nursing?

No

Yes

If Yes, services are limited.

Do you have metal implants?

No

Yes

If Yes, services are limited.

If Yes, where?

Do you smoke tobacco regularly?

No

Yes

Do you participate in vigorous aerobic activity / sports??

No

Yes

If Yes, how many times per week?

If any, how often?

Last breakout?

What area?

Do you wear contact lenses or have sensitive eyes?

No

Yes

If Yes, please remove contacts prior to services.

Do you wear sunscreen on a regular basis?

No

Yes

Have you visited a tanning booth within the last week?

No

Yes

If Yes, services may be rescheduled.

Are you currently taking any antibiotics?

No

Yes

If Yes, services may increase your sensitivity.

PERSONAL CARE

(Please select all that apply)

Are you currently using products containing Glycolic Acid or AHA?

No

Yes

If Yes, how long have you been using the product?

How has your skin been reacting to it?

Great

Good

Poor

Are you currently using Acutance?

No

Yes

If Yes, how long have you been using the product?

Have you ever used Hydroquinone (skin lightener)?

No

Yes

If Yes, how long have you been using the product?

Have you have permanent make up?

No

Yes

If Yes, what area?

PROFESSIONAL CARE

(Please select all that apply)

Microdermabrasion?

Yes

No

If Yes, When?

Chemical Peel?

Yes

No

If Yes, When?

Laser Resurfacing?

Yes

No

If Yes, When?

If Yes, What Area?

Collagen or Botox?

Yes

No

If Yes, When?

If Yes, What Area?

Cosmetic Surgery?

Yes

No

If Yes, When?

If Yes, What Area?

Electrolysis?

Yes

No

If Yes, When?

If Yes, What Area?

SKIN COMPLEXION

(Select all that apply)

SKIN APPEARANCE

(Select all that apply)

QUESTIONNAIRE

What improvements would you like to see with your skin?

What products do you currently use on your skin?

What type of facial treament did you last have?

(indicate N/A if you have not had a facial)

What did you enjoy most about the treatment?

What did you enjoy least about the treatment?

CONSENT / AGREEMENT

Consent Agreement

<em>I affirm that I have stated all my known medical conditions and answered all questions honestly.  I agree to keep the provider updated as to any changes in my medical profile and understand that there shall be no liability of the service provider should I fail to do so.  My questions regarding the treatment have been answered satisfactorily.

I understand the treatment and accept any risks.  I hereby release Beverly Hills Day Spa from all liabilities associated with the above indicated treatment. I agree that this consent supersedes any previous verbal or written disclosures.

This consent / agreement is valid for all of my facial treatments in the future as well. </em>

CANCELLATION POLICY

<em>Our Massage Therapists, Nail Technicians, and Skin Care Specialist base their livelihood on time, therefore, as a courtesy please give as much notice as possible if you must cancel an appointment Less than 24 hrs.

Cancellations & No Shows will be charged 50% of the services that were scheduled, and Gift Certificates are to pay 30% of missed appointment before service is further rendered to them.

Thank you for your kind understanding.</em>

Print Client Name

Signature

Clear

Date

TREATMENT OF A MINOR

I hereby authorize the specialist to administer a facial or waxing to my child/dependent.

Print Guardian Name

Guardian Signature

Clear

Date