U&I Spa Inc

Please answer all questions below and press the [SUBMIT] button on all forms.

1. PERSONAL INFORMATION

*Name

*AddressStreet Name, #, City, State, ZIP

*Birthdate

*Phone Number

*Emergency Contact Phone Number

*Relationship

*Email

*What treatment/s are you doing today?

How did you hear about us?

2. MEDICAL INFORMATION

*Are you taking any medication?

Yes

No

*If Yes, please list medications you are taking below

*Do you have any allergies and/or current or past medical conditions?

Yes

No

*Please list any allergies and/or current or past medical conditions:

What is the date of your last dermatology visit?

3. HEALTH HABITS

*Do you...

*Smoke?

Yes

No

*If yes, how often do you smoke? (__ times per day/week/month)

*Drink alcoholic beverages?

Yes

No

*If yes, how often do you alcohol? (__ times per day/week/month)

*Consume caffeinated beverages?

Yes

No

*If yes, how often do you drink caffeinated beverages? (__ times per day/week/month)

*Exercise?

Yes

No

*If yes, how often do you exercise? (__ times per day/week/month)

*How many cups of water do you drink per day?

*What is your stress level? (1, None – 10, High): _____

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4. SKIN CARE HISTORY

Please list skin/body concerns: (wrinkles, acne, rosacea, loose skin, wrinkles etc.)

Please list current medications taken, skin care products, brands and routine: (moisturizers, cleansers, serums, masks, etc.)

*Do you use Retinol (Retin-A)?

Yes

No

*If yes, date of last application:

*Have you ever had a facial before?

Yes

No

*If yes, when was your last facial or service with us?

What other improvements would you like to see with your skin/body? (Optional)

Is there anything else we should know? Please discuss with our aesthetician & sign below before submitting. Thank you!

5. CLIENT 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/body from treatments received.

I have discussed all I need to know with my aesthetician. My aesthetician has thoroughly informed me about the procedure, any risks and aftercare.

The treatments I receive here are voluntary and I release this institution, U&I Spa and/or skin care professional from liability and assume full responsibility thereof.