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Newmarket: (905) 953-8688 | Barrie: (705) 719-6888
MAKE AN APPOINTMENT
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Newmarket: (905) 953-8688 | Barrie: (705) 719-6888
MAKE AN APPOINTMENT
FORMS
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Esthetics Intake Form
Personal Information
Your Name
(Required)
First
Last
Phone
(Required)
Email
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Date of Birth
MM slash DD slash YYYY
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Street Address
Address Line 2
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Esthetics Information
Which aroma(s) do you prefer? (Please select all that apply)
(Required)
Lavender
Rose
Jasmine
Orange
Lemongrass
Peppermint
Tea tree
Pine needles
None
What type of skin do you have?
(Required)
Normal
Oily
Dry
Combination
Sensitive
I don’t know
What areas of concern do you have regarding your skin?
(Required)
Acne
Blackheads/Whiteheads
Excessive Oil/Shine
Wrinkles/Fine Lines
Redness
Uneven Skin Tone
Sun Damage
Rosacea
Dehydrated
Dull/Dry Skin
Sun, Liver, Brown Spots
Other
Select All
Please describe if you choose other
Have you been under the care of a dermatologist within the past year?
(Required)
Yes
No
If yes, please explain
Do you have any allergies?
(Required)
Yes
No
If yes, please specify
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?
(Required)
Yes
No
If yes, please specify
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
(Required)
Yes
No
If yes please describe
Consent
(Required)
I agree to the policy.
By signing below, you agree to the following:
I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my esthetician and the employer for any injury or damages incurred due to any misrepresentation of my health history.
Signature
(Required)
Please sign using your finger or a mouse.
Date
(Required)
MM slash DD slash YYYY
Home
About
Services
RMT Massage Treatment
Facial Treatment
Acupuncture Treatment
Esthetic Body Services
Intense Pulse Light Therapy (IPL)
Body Contouring Treatment
Microneedling / Microdermabrasion
Packages
Other Services
Promotions
Membership
Gift Cards
Contact
