Client Record: Facials & Waxing

Please complete this form. This information is critical to your session(s) as it may affect the focus and outcome of it. All information disclosed will be kept for session purposes only and in strict confidentiality.

First Name

Last Name

Appointment Date

Appointment Time

Scheduled Treatment

Personal Skin Health History

Are you currently under the care of a Dermatologist?

Yes

Are you using any oral or topical medications that would be relevant to your session today?

Yes

If so, what? (i.e. Retin A, Tazorac, Differin, etc)

Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 hours?

Yes

Have you had any Microdermabrasion or Dermabrasion in the past 2 weeks?

Yes

Have you had any chemical peels within the last week?

Yes

If yes, describe them.

Have you been over exposed to the sun, or been on a tanning bed in the last 24 hours?

Yes

Have you had any cosmetic tattooing in the area to be treated?

Yes

If so, where?

Do you have any metal, or other, implants?

Yes

If yes, describe them.

Do you have any allergies to aspirin, fragrances, essential or plant oils used in skin care products?

Yes

If so, what?

Have you had any recent hair removal treatments in the area to be treated?

Yes

If so, what and where?

Have you had any Botox or filler injections?

Yes

If so, when and where?

What is your skin type?

Oily

Normal

Dry

Combination

If you are receiving a facial, what are you most interested in today?

Relaxation/Pampering

Renewed Appearance/Anti-Aging

Deep Cleansing/Purification

Information/Skin Health

**If you experience any pain during the session(s), please immediately inform the therapist, so that the work can be adjusted to your level of comfort.

I confirm that, to the best of my knowledge, the answers above are correct, and I have not withheld any relevant information. I hereby agree to hold eména spa and its staff members harmless in the event I sustian any injury or damage to my person, direclty or indirectly, as a result of receiving spa and beauty treatments. I agree to release emena spa and staff memebers from any claim; cause of action, suit, damages etc. that may result from any such injury or damage. I understand that os I am using accutance, Retin A or any exfoliants on my skin prior to my session that it can cause irritation and that I will inform my esthetician prior to my waxing or facial services. I agree to keep the spa updated as to any changes to my medical profile, and I understand there will be no liability on the spa or the therapist's part if I fail to do so.

Signature

Date

Client Record: Facials & Waxing

Personal Skin Health History

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