First and Last Name
Date of Birth
Emergency Contact Name and Phone Number
How Did You Hear About Us? Select All That Apply.
Referral (please name below)Walkng/ Driving byGoogleFacebookInstagramPromotionOther
Rate your level of stress: (5=highest, 1=lowest) 5 4 3 2 1
Do you wear contact lenses?
Please list any allergies you might have
Please list any medications you are taking
Please check any of the following health conditions you may have:
Heart ConditionLymph EdemaHerpes/ShinglesHigh Blood PressureLow Blood PressureNumbness/TinglingSinus ProblemsAllergiesChronic PainVaricose ViensRashesJaw Pain/TMJBlood ClotsSprains/StrainsDiabetesHeadachesArthritisSpasms/CrampsPregnacy(____weeks)Fatigue/Sleep DisorderCancerRecent SurgeryOther
What are your skin care goals?
Are you under the care of a dermatologist?
Do you use:
AccutaneRetin ARenovaAdapaleneAnti-BioticsOther prescription skin products
Have you had a:
Chemical PeelMicrodermabrasionInjections (botox, fillers)Other resurfacing treatments
Are you currently using any products that contain:
Glycolic AcidLactic AcidHydroxy AcidVitamin A (Retinol)Vitamin C
Do you have any skin sensitivities or irritants?
It is my choice to receive services at Eden Day Spa. I have completed this form to the best of my knowledge. I have stated all medical conditions that I am aware of and I will update Eden Day Spa of any changes to my health status. I understand that Estheticians and Massage Therapists do not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments, pharmaceuticals, or perform spinal manipulations. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and it is recommended that I see a primary health care provider for that emergency. If I miss a scheduled appointment without giving 24 hours notice, I agree to pay the missed appointment fee that may apply
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