THE DAY SPA

Skin Consent Form

Download PDF Form

--------------------------

Date Of Appointment (Month/Date/Year)

Full Name

Date of Birth (Month/Date/Year)

Address

City

State

Zip

Email

Cell Phone

Home Phone

Pls select your preferred method of communication for future appointment confirmation:

How did you hear about us? (If referred by someone, please list name)

HEALTH HISTORY

Have you been to a dermatologist within the last year?

Reason for visit

Are you presently under a Physician’s care?

Reason for visit

Are you currently taking any medications?

If yes, please list

Are you pregnant, lactating or trying to conceive?

How would you rate your general skin health?
Please rate your stress level from 1-5 (5 being the highest) 1 2 3 4 5

Excellent

Good

Fair

Poor

Have you experienced or have any of the following?

Hypertension

Hernia

Stroke

Epilepsy

Diabetes

Cold sores

Lupus

Hepatitis

Contacts

Headache

Anemia

Thyroid Disorder

Irregular pulse

Varicose veins

Fainting

Cancer

Eating disorder

High cholesterol

Metal Plates/Implants

Seizures

Asthma

Heart attack

High/low Blood pressure

Do you take nutritional supplements?

If so, what?

Do you exercise?

Do you smoke?

Do you consume alcohol?

Do you have tendency to scar?

Allergies
Have you ever had an allergies reaction to any of the following?

Aspirin or Salicylates

Fish, marine or iodine

Milk

Latex

Apples

Citrus

Grapes

Specific Ingredients in skincare products

If checked yes to any of the above, please explain

Please list any other known allergies

Have you ever had Herpes Simplex?

If yes, have you ever been treated with Denavir (Penciclovir), Zovirax (Acyclivor), or Abreva?

Are you being treated for Hepatitis?

Are you on hormone replacement therapy?

If so, please list

Are you presently taking birth control?

Please choose

Other

Brand

Skin Care History
Home Care

What skincare products are you currently using at home?

Cleanser

Moisturizer

Serum

SPF

Toner

Exfoliant

Mask

Other

Please check if you take or use any of these:

Benzoyl Peroxide

Sulfur

Glycolic Acid

Vitamin A

Lactic Acid

Vitamin C

Salicylic Acid

Hydrocortisone

Resorcinol

Hydroquinone

Please check any prescriptions you take:

Tretinoin (Retin-A, Micro, Renova, Avita)

Tazarotine (Tazorac)

Metrogel

Adepalene (Differin)

Isotretinoin (Accutane)

Azelaic Acid (Azelex, Finacea)

Triluma

Any other topical antibiotics?

Have you had any of the following services?

Chemical exfoliation (Peel)

Fillers

Laser Resurfacing

Botox Injection

Waxing

Microdermabrasion

Collagen Injections

Light Treatment

Hair Treatment (Perm, Color, Etc.)

Permanent Cosmetics

laser hair removal

Do you use sunscreen daily?

Level of protections? SPF

Do you sunbathe or participate in outdoor activities?

Do you use a tanning bed?

If Yes, have you tanned in the last 14 days?

Have you had any direct sun exposure in the last 10 days?

When exposed to the sun do you:

Do you feel your skin sensitive?

When exposed to the sun do you tend to have:

Is there any other necessary information your licensed Esthetician should know before beginning your treatment?

If yes, please explain

My main skin concern is

I acknowledge that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and home care products to achieve the desired results. Results cannot be guaranteed due to individual skin type(s) and condition(s). I agree to inform my technician to any changes pertaining to the above questionnaire. I further agree to all post-care instructions as I am directed.
You must agree before submitting.

Electronic Aknowledgement

Date Today (Month/Date/Year)

The Day Spa

A full spa experience to encourage self care and stress management. The Day Spa proudly services the Greater Green Bay area as a premier salon and spa. The nurturing sanctuary and tempting choices of over 100 treatments designed to reinvigorate the mind, body and soul. It's time... For you.

Useful Links

HOME

ABOUT US

SHOP WITH US

CAREERS

EMPLOYEE PORTAL

Contact Us

600 N. 10th St. De Pere, WI 54115
Mon-Thurs, 9am - 9pm
Friday, 9am - 7pm
Saturday, 9am - 6pm
Phone: (920)-339-5250
Email: events.dayspaescape@gmail.com

CONNECT WITH US!

© Copyright The Day Spa. All Rights Reserved

Designed by: I AM LLC