First and Last Name
Date of Birth
Address
City
US States
Zip
Email
Phone
Emergency Contact Name and Phone Number
How Did You Hear About Us? Select All That Apply. Referral (please name below)Walkng/ Driving byGoogleFacebookInstagramPromotionOther
Referral
Rate your level of stress: (5=highest, 1=lowest) 5 4 3 2 1 12345
Do you wear contact lenses? YesNo
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
More information
What are your skin care goals?
Are you under the care of a dermatologist? YesNo
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
