Michelle's Hidden Spa Skincare Intake Form

Date

MonthDayYear

Referred By

Google, Yelp, Facebook, etc.

Name

First NameLast Name

E-mail Address

Birthdate: Month & Day

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

What are your main skin concerns?

If you could wave a magic wand how would your skin look in one month?

Any special requests for today? (Extractions, skin soothing, eye treatments, hand & foot treatments, hydration, relaxation, sinus massage, aromatherapy scalp massage)

Medical, Health, Bodily Conditions: Is there anything I need to know before we get started? The more I know, the better your results. (Please List: allergies, sensitivities, pregnant, stress level, nursing, health issues, diabetic, medications, metal plates, cold sore, Retina A use or any topic products that might cause skin sensitivity).

What skin type best describes your skin? (Oily, combination, dry, etc)

List skincare brands that you use and your regimen (cleansers, serums, moisturizer, sunscreen, exfoliants)

What did you LOVE about your last facial, and what could you have lived without?

Home care is key to maintaining your glow between facials.

I’d love some personalized tips to keep the glow goingJust here to relax

Anything else you want to share? I love learning about my clients as it helps me provide superior customer service.

I understand that Michelle’s Hidden Spa services including facials and body treatments given at Michelle’s Hidden Spa, are for the sole purpose of skin cleansing, body, and mind relaxation and rejuvenation.

I agree

I understand that it is imperative to tell my Esthetician about any oral or topical medications prior to any facial, body treatment services, or massage.

I agree

I understand that Michelle’s Hidden Spa and staff do not diagnose illness, diseases, or any other physical or mental disorder. I accept full responsibility of the use of Michelle’s Hidden Spa at my own risk, and to not hold Michelle’s Hidden Spa or staff liable for loss, damage, or injury.

I agree

I understand that results are personable and not guaranteed.

I agree

I confirm that to the best of my knowledge that the answers given on client consultation form are correct and that I have not withheld any information that maybe relevant to my treatment at Michelle’s Hidden Spa.

I agree

I understand that I must provide at least 24 hours advance notice for the cancellation of an appointment.

I agree

I understand Michelle’s Hidden Spa has a strict 24 Hour Cancellation Policy. In the event of a late cancellation/no show the fee is full price of the service. Card will be charged for the no show and late cancellation. Gift certificates will forfeit gift certificate for late cancellation and no show. For packages you will lose one of your sessions for no show and late cancellation.

I agree

Late arrivals may result in a shortened treatment time to ensure the next guest is not delayed. The full amount of service will still be charged.

I agree

Clients who frequently reschedule their appointments at the last minute, three or more times, may be subject to termination of services.

I agree

I understand there are risks associated with skincare treatments. Such as redness, sensitivity, peeling, inflammation. Any additional concerns I will discuss with my practitioner.

I agree

*Please note any additional information that may be of importance to your Licensed Esthetician regarding the spa treatment you will be receiving.

After hitting submit please book your appointment. A wait list is available for your desired time and day by clicking on the wait list button on the website.

Signature

Date

MonthDayYear