Check – In Page – "Radiate Your Natural Beauty From The Inside Out"

Today's Date *

Name *

First

Last

Date of Birth (Optional)

For birthday specials and or discounts

Street Address *

Phone Number *

Primary Care Physician(if unknown, write n/a):

Dermatologist(if unknown, type n/a):

Emergency Contact (Name & Number): *

Your Occupation(optional):

Referred by: *

Esthetician Name:

Your last Skin care Specialist, If none, write N/A

Is This Your First Visit to The Salon/Spa? *

What is the primary reason for your visit today? *

What special areas of concern do you have? Please check all that apply. *

Please explain your concerns in detail here:

Have you ever had a facial treatment before: *

If yes, when was your last treatment?

How would you describe your experience?

Additional Comments:

Have you ever had any of the following? If yes, please state the date of last treatment next to all that apply.

Medical History/ Contraindications *

Are You On Any Medication? (List Below, if None type N/A) *

Do You Have Any Allergies? (List Below, if None type N/A) *