Name * First Name Last Name Email * Phone * (###) ### #### What service are you getting? * What is your goal for todays session? * When was your last treatment? * What did you like and /or dislike about it? * What would make today's experience amazing? * What does your daily self-care routine look like? Any details are welcome What is your stress level? * O - None 1 2 3 4 5 - Off the charts Health History It is not advisable to engage in certain treatments where specific medical conditions exist or treatment occurred recently. Do you have any of the following conditions? Cancer Pacemaker Headaches/Migraines Hormone Imbalance Heart Conditions Epilepsy/Seizures Osteoporosis/Arthritis Ashtma Blood clots/Thrombosis Diabetes Numbness Chronic Pain Claustrophobia Varicose Veins Kidney/Liver Disease Herpes Hepatitis Autoimmune Disorder Swelling Fungus/Warts Pregnant - Currently Skin Health It is not advisable to engage in certain treatments where specific medical conditions exist or treatment occurred recently. Do you have any of the following conditions? Eczema Psoriasis Rosacea Acne Bruising/swelling Skin Allergies Oily Complexion Hypo/Hyper Pigmentation Dry Complexion Ingrown Hairs Eye Allergies/ Irritation List any medications, supplements, and/or recent surgeries If you checked yes to allergies, please list them here Have you used any of the following products in the past month? Accutane Retin- A, Retinols/Vitamin A AHA/BHA (Glycolic Acid, Lactic Acid, Salicylic Acid) Not Sure Have you ever reacted from a product or service? * Rash Irritation Peeling Sun Sensitivity Breakout (surface breakouts) Breakout (deep, under the surface) No Other Other, please explain At this time, does having regular professional treatments on a consistent basis appeal to you? Yes No I only like them as a treat once in a while Other If other, please explain Please note any additional concerns not previously listed Is there anything else that we should know about you that we have not asked that can help us to better serve you? Consent & Acknowledgement of Policy * Please check all below I authorize Spa la Vie to perform the treatment I have selected I agree to treat the employees of Spa la Vie in a professional courteous manner I understand that I or the licensed professional may terminate the service at any time I release Spa la Vie from any responsibility or liability in case of accident, illness or injury I understand that there are many variables that may influence the results of my service, including but not limited to hair growth cycle, hormone cycle, personal use of cosmetics and other skin care products, diet, metabolism, and skin/body type I understand that multiple sessions for some services is required to achieve results, and that no guarantee has been given I confirm that I do not have any existing medical conditions that I am aware of that can affect the spa service selected I agree that if I cancel for any reason with less than 24hrs notice or No Show my appointment I will be charged for the missed service I acknowledge that refunds will NOT be given for any reason or circumstance. Photo consent: For insurance and treatment progression purposes we need to have a photo on file for some services. This question is to ask if you mind if we use your photo for general marketing? We will not share any private info * Specific for Lash, Brow & Facial Clients Yes, use any picture Maybe, depends on what is being used No If someone referred you to Spa la Vie, please share their name below so we can thank them Thank you! We can’t wait to see you soon!!In the meantime, we would love it if you head to our Instagram and give us a quick follow! Please complete the following so we can provide the safest, most effective and thoughtful treatment EVER!This form is not to be used as an appointment request.
