Facial Intake Form | Palm Tree Day Spa

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Confidential Skin Health Questionnaire

Name *

Email *

Address: *

Please incl. Zip Code and any Unit /Apt #s

Contact Phone: *

Cell Phone #s are best, as we prefer to text you a messages instead of calling you.

Client History

Have you had any facial treatment in the past? *

Yes

Do you have any allergies? *

Yes

If yes, please list *

Have you ever seen a dermatologist? *

Yes

If yes, have you been medically diagnosed with any skin conditions? *

Yes

If yes, please list *

Are you currently taking any medications, prescribed and/or over the counter? *

Yes

If yes, please list *

Have you taken Accutane in the last year? *

Yes

Are you currently using any medicated facial ointments or creams? *

Yes

If yes, please list *

Do you get Botox and/or fillers? *

Yes

If yes, when was your last treatment? *

Do you suffer from any medical conditions, current or past? *

Yes

If yes, please list *

Do you have high blood pressure? *

Yes

Do you have any metal face and/or body implants? *

Yes

Have you ever had any face and/or body surgeries (including plastic surgery)? *

Yes

If Yes, Please Describe:

Do you use retinoids/retinol? *

Yes

Have you ever had a chemical peel? *

Yes

If yes, when was your last peel? *

When was your last facial waxing treatment?

Have you ever had facial laser hair removal or laser resurfacing? *

Yes

If yes, when was your last treatment? *

What skincare products are you using at home?

Please list type & brand

Client Certification of Information and Consent

Client Signature *

Typing in your name is fine.

Date *

Clicking box will open Calendar

By my signature above, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge. By signing this form, I consent to receive treatment from the Palm Tree Day Spa

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