Spa Screening Form
Spa Screening Form
Name
Address
Phone number
Emergency Contact Name
Emergency Contact Phone Number
Current Medical Conditions
Allergies (e.g., to products, foods, medications)
Current Medications (including supplements)
Previous Surgeries or Injuries
Are you currently pregnant or trying to conceive?
Skin and Body Concerns
Skin Type
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Oily
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Dry
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Combination
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Sensitive
Specific Skin Conditions
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Acne
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Eczema
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Psoriasis
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Rosacea
Areas of Concern
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Acne/Blemishes
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Fine Lines/Wrinkles
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Hyperpigmentation/Dark Spots
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Redness or Irritation
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History of Reactions to Spa Treatments
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No previous reactions
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Mild irritation/redness
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Allergic reaction (e.g., swelling, rash)
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Breakouts following treatment
Services Interested In
Specific Areas of Focus or Avoidance
Additional Notes
Preferred Appointment Date and Time
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