Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Do you prefer text messages?

Yes

No

Are you currently under medical supervision?

Yes

No

Do you have any food allergies? Allergies to latex or any other allergies? *

Yes

No

Do you have any of the following? *

Please check all that apply. Note: You may be denied certain services if you have any of the below health conditions.

Epilepsy

Heart Condition

Pacemaker

Skin Cancer

Skin Diseases

Recent Operations

Diabetes

Asthma

Arthritis

High Blood Pressure

Hemophilia

Metal Implants

None of the Above

How would you describe your skin? *

Oily

Dry

Combination

Sensitive

Are you currently using: *

Please check all that apply.

Accutane

Retin-A

Renova

Glycolic Acid

Lactic Acid

Hydroxy Acid

Vitamin A

None of the above

Do you tan easily? *

Yes

No

Do you get an oily shine throughout the day? *

Yes

No

Sun Exposure: *

Please choose one.

Light

Moderate

High

How would you describe your stress level? *

Little

Moderate

High

Severe

Do you wear sunscreen daily? *

Yes

No

Do you cleanse your skin morning and night?

Yes

No

Do you prefer massage pressure to be mild, moderate, or firm?

Mild

Moderate

Firm

Are you pregnant and/or nursing? *

Yes

No

Do you smoke? *

Yes

No

Have you tanned or used a tanning bed within the last 48 hours? *

Yes

No

What are your areas of concern? *

Please check all that apply

Sun Damage

Acne

Fine Lines & Wrinkles

Blackheads

Discoloration

Scarring / Texture

Facial Hair

Body Hair

Thin or Misshaped Brows

Redness or Rosacea

Cellulite

Rough Skin or Keratosis Pilaris

Dry Skin

Sensitive Skin

Lack of Skin Tone (Firmness)

Dullness

Dark Circles Under Eyes

Puffiness Under Eyes

None of the Above

What skin care products are you currently using? *

Please check all that apply

Cleanser

Toner

Serum

Scrub

Mask

Eye Cream

Moisturizer

Self-Tanner

Sunscreen

Concealer

Makeup

None of the Above

Do you agree to avoid direct sun after treatment? *

Yes

No

Do you currently have any active cold sores? *

Yes

No

Do you agree to notify us as soon as possbile with any concerns? *

Yes

No

Do you agree to our cancelation policy? *

Cancellation Policy: I agree to cancel my appointments 24 hours in advance. If I miss a scheduled appointment without giving 24-hour notice, I agree to pay 50% of the scheduled service fee. If I do not call or show for my scheduled appointment I agree to pay full price for my scheduled service.

Yes

No

*

It is my choice to receive spa therapies. I have completed this form to the best of my knowledge. I affirm that I have stated all known medical conditions including all known allergies or prescription drugs or products I am currently using. I agree to update Belle Ame Beauty and Wellness of any changes to my medical profile and understand there shall be no liability on the esthetician/therapist’s part should I fail to do so. If I experience any pain or discomfort during my session I will immediately inform my esthetician/therapist. I give my permission to my esthetician/therapist to perform the procedures we have discussed and will hold them and Belle Ame Beauty and Wellness harmless from any liability that may result from this treatment. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my esthetician/therapist immediately.

Agree

Disagree