BELLA SOUL SPA INTAKE/RELEASE FORM
FACIALS, WAXING, TINTING AND GLYCOLIC/ ENZYME PEELS
Name: __________________________________________________________ Date of Birth: _________________
Address: _____________________________________________________________________________________
Phone:__________________________________ E-mail address: ________________________________________
Referred by: ___________________________________________________________________________________
FACIALS, WAXING AND PEELS:
YES
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NO
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1) Have you used a scrub, glycolic, microdermabrasion, had laser hair removal, electrolysis,
used a tanning bed or waxed the area of today’s treatment in the last 30 days?
2) Do you use Retin-A, Renova, had a deep chemical peel by a doctor, facial surgery or laser
resurfacing or used Accutane within the last 18 months?
3) Are you presently under the care of a dermatologist?
4) Are you taking any medications (particularly hormones, acne medication such as Accutane,
anti-biotics, Differin, Retinols or blood thinners such as aspirin or Coumadin?
If so, please
list_______________________________________________________________________________________
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5) Do you have any communicable diseases right now such as cold sores or the flu?
6) Have you experienced Botox, Restylane or Collagen injections? When?_______________
7) Have you recently used any self-tanning lotions, creams or treatments?
8) Are you taking birth control or HRT? Any recent changes to or from your contraceptives?
9) Are you pregnant or trying to become pregnant or lactating?
FACIAL AND PEEL CLIENTS ONLY:
List all allergies including plant/vegetable products, cosmetics and medications:
_________________________________________________________________________________________
What would you like to achieve from your treatment today?
____________________________________________
What products do you currently use to treat your skin? _____________________________________________
Do you use Sunscreen? ___________ Do you use mineral makeup? ___________________________________
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure,
and that it supersedes any previous verbal or written disclosures. I understand that withholding information or
providing misinformation may result in contraindications and/or irritation to the skin from treatments received.
The treatments I receive at BELLA SOUL SPA INC are voluntary and I release BELLA SOUL SPA INC and/or licensed
Esthetician from liability and assume full responsibility thereof.
Client Signature: ________________________________________________________Date:_____________________
Consent to Treatment of Minor
By my signature below, I hereby authorize a BELLA SOUL SPA INC to administer a facial or waxing to my child
or dependent, as they deem necessary.
Guardian Signature _____________________________________________________Date______________________