Spa New Client Intake Form

CLIENT INFORMATION:

Name: *

Today's Date: *

Home Phone Number:

Cell Phone Number: *

Email: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate: *

Age: *

Gender: *

Occupation

Years on job

Are you currently a client of The Well of Life Center? *

Yes
No

If yes, who is your Clinician?

In Case of Emergency, please contact:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Relationship: *

Health & History Questionnaire

Check all CURRENT conditions:

Check all PAST conditions:

* If yes, you will be treated only with a doctor's release

Have you ever had herpes (cold sores)? *

Yes
No

If yes, have you ever been treated with Zovirax or any medication for herpes?

Yes
No

Have you received a massage before? *

Yes
No

If yes, when?

Have you had a facial before? *

Yes
No

If yes, when was your last facial?

How do you rate your stress level?

Are you presently under a doctor's care? *

Yes
No

What medications do you take on a regular basis?

Do you take nutritional supplements? *

Yes
No

Do you have any allergies? *

Yes
No

If yes, please list:

Do you wear contacts? *

Yes
No

Do you smoke? *

Yes
No

Are you on a diet? *

Yes
No

Do you exercise? *

Yes
No

How is your general health? *

Excellent
Good
Fair
Poor

Do you have any special needs your technician should be aware of?

Skin Care History Questionnaire

What concerns you most about your skin today? (Mark all that apply)

Have you ever had an allergic reaction to any skin product or cosmetic? *

Yes
No

If yes, please list:

If you are here for a facial or waxing, are you using any of the following on your skin?

What skin care products are you currently using? *

Have you ever had an allergic reaction to any skin product or cosmetic? *

How often do you cleanse your face? *

Once a day
Twice a day
More often
Less often

Do you use an exfoliant? *

Yes
No

If yes, how often?

Do you use a moisturizer? *

Yes
No

If yes, how often?

Do you use an eye cream? *

Yes
No

If yes, how often?

Do you use sunscreen/sunblock? *

Yes
No

Do you sunbathe or participate in outdoor activities? *

Yes
No

Are you allergic to aspirin? *

Yes
No

Are you allergic to iodine or seaweed? *

Yes
No

Do you use Biore or snore strips? *

Yes
No

Do you or have you ever had acne? *

Yes
No

Are you using or have you ever used any medications for acne? *

Yes
No

If yes, please name the medication:

Have you ever had electrolysis or waxing in the past? *

Yes
No

If yes, do you have those services done regularly?

Yes
No

Have you had permanent cosmetics? *

Yes
No

If yes, where?

Have you seen a dermatologist in the past year? *

Yes
No

If yes, list doctor's name and reason for visit:

Have you had any of the following?

What is it about your skin you would like to change?

Well of Life Spa Policies and Liability Release Form and Agreement and Release of Liability: *

Please click HERE to read our Policies and Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Spa Policies and Liability Release Form and Agreement and Release of Liability.

Spa New Client Intake Form

New Client Appointment Checklist

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

New Client Form

CLIENT INFORMATION:

In Case of Emergency, please contact:

Health & History Questionnaire

Skin Care History Questionnaire

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