Ingredients and techniQues for smarter skin
Boutique
NO H²0 Hand Sanitizer
Eye Treatment
Lip Treatment
Serums
Masks
Face Creams
Body Moisturizers
Body Care Services
Spa SkinCare
Spa Waxing
SkinGenius® Rewards
Contact
Book An Appointment
Ingredients and techniQues for smarter skin
Boutique
NO H²0 Hand Sanitizer
Eye Treatment
Lip Treatment
Serums
Masks
Face Creams
Body Moisturizers
Body Care Services
Spa SkinCare
Spa Waxing
SkinGenius® Rewards
Contact
Book An Appointment
Client Profile
Confidential Client Health History Form
Name
*
First Name
Last Name
Date of Birth
*
* anyone under the age of 18 years old must have a parent/guardian's consent prior to receiving any Skin IQ Spa Services
MM
DD
YYYY
Address
Best Number to Reach You
*
(###)
###
####
Emergency Contact
*
Name & Number
Email Address
*
Sign me up for the Skingenius Loyalty Program!
*
As a loyal customer, we will reward you for achieving smarter looking skin. Who doesn't want to increase their skin's IQ? And because you want to increase your skin's intelligence, we will award you 100 points, just for signing up!
Yes please!
No thanks
Have you ever had a body spa treatment before
*
Yes
No
What Spa Services/Treatments have you experienced before?
Have you ever had an adverse reaction after using any skin care product?
*
Do you have any allergies (medicine, food, other)
*
List Any Medications Currently Taking
*
Have you had any health conditions in the past or present (Cancer, Diabetes, High Blood Pressure, HIV/AIDS, Hepatitis, Herpes, Lupus, Skin Disease/lesions, Any Active Infection, etc)?
*
Do you have any metal implants or wear a pacemaker?
*
Yes
No
Do you use Retin-A, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid, or Retinol/Vitamin A derivative products?
*
Yes
No
Have you used any of these products in the last 3 months?
*
Yes
No
Signature
*
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care professional of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
I consent
Date
*
MM
DD
YYYY
Thank you!
