Name
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First Name
Last Name
Email
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Phone
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(###)
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####
Date of Birth
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Emergency Contact: Name, Phone Number, Relationship to Client
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What is your skincare and makeup regimen?
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Select each method you use
Have you ever had a facial?
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If yes, when was your last facial?
Do you have any special skin concerns pertaining to your face and/or body?
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What would you like to achieve with your treatment today?
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How much water do you consume daily?
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How much caffeine do you consume daily?
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How much alcohol do you consume per week?
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Do you smoke?
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If yes, how many cigarettes fo you smoke daily/weekly?
Do you exercise?
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If yes, what types of exercise do you do and how often?
Do you take vitamins or supplements?
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If yes, which vitamins or supplements and how often?
Do you take any medications?
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If yes, which medications do you take?
Have you seen a dermatologist within the last 12 months? If so, what was their recommendation and/or diagnosis?
Do you currently, or have you in the past taken Accutane?
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Do you currently, or have you in the past taken Retin-A?
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Do you currently, or have you in the past taken Renova?
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Do you currently, or have you in the past taken Adapalene Hydroxy?
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Do you have any known allergies?
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If yes, please indicate all dietary, medical, and topical allergies you have.
Are you currently taking birth control?
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If yes, which type of birth control.
Are you currently pregnant or breastfeeding?
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If pregnant, how far along are you? If breastfeeding, when did you give birth?
Do you have any restrictions on your diet?
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If yes, please indicate which restrictions:
Are you currently or have you in the past two weeks past experienced any cold, flu, or other illness symptoms?
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If yes, please describe.
Do you ever experience claustrophobia?
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If yes, please explain in detail when you experience this condition.
By submitting this form, I understand, have read, and have completed the above intake form truthfully and to the best of my ability. I agree that this document constitutes full disclosure and by withholding any information about my skin and/or health may cause contraindications and/or irritation to my skin during the treatment. The treatment I receive is voluntary and I release Girl on the Go Wellness Spa and all technicians working on me from liability and assume full responsibility thereof.
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