New Client Facial Form

Name *

Email address *

Phone number *

Date *

Appointment for a minor under the age of 18? *

No

Yes

Do you have any allergies or sensitivities? *

Please estimate your daily sun exposure. *

30 minutes or less

1-2 hours

3-4 hours

5 hours +

Have you had a facial before? If so, when was your last treatment? *

Do you have a current home care regimen? *

How consistently do you follow your home care regimen? *

N/A

Daily

Weekly

Sparingly

If you would like, upload an image of your product for feedback:

Please let us know if any of the following conditions apply to you, as they may partially or fully contraindicate your treatment. *

Please select at least one option.

Medications including: Acutane, Differin, Tazarac, Azelex, AHA/BHA Peels, Renova

Often use of tanning beds

Use of Retin-A products

Pregnancy

Immune deficient

Cardiac problems/pacemaker

High blood pressure

Blood clots

Botox or other injectables

Cancer

Hormone replacements

Epilepsy

Kidney problems

Diabetes

I'm unaware of any medical conditions, and the above conditions do not apply.

Please explain any of the above conditions that apply. I (the client) understand that if I choose not to disclose this information to the service providers that I cannot hold Awaken-Zen Spa responsible in any legal capacity if an issue arises. *

Please check any of the skin conditions that are concerning you: *

Please select at least one option.

Hyperpigmentation

Acne

Redness

Rosacea

Sensitivity

Oiliness

Dryness

Clogged pores

Flaking skin

Aging skin

Are you interested in skin care education? *

No

Yes, after the session only.

Yes, during and after session is okay.

Do you have any specific requests or goals for your treatment, both short and long-term? *

Please select at least one option.

I understand that by acknowledging here, I (the client) have provided all information requested and withhold Awaken-Zen Spa from all legal liability if information was not disclosed. *

Please select at least one option.

I authorize and request facial treatments from Awaken-Zen Spa. *

Please select at least one option.

I have reviewed the HIPAA disclosure in the URL below. I understand my rights and consent to how my personal information will be handled and disclosed in accordance with the HIPAA guidelines. URL: www.awakenzenspa.com *

Please select at least one option.

Please acknowledge that opting for an upgraded service during your visit my incur additional cost and that verbal consent by you (the client) will be sufficient notice of the change in price. *

Please select at least one option.

"I acknowledge that Awaken-Zen Spa requires a $25 prepayment to book my appointment. To receive a refund, I must cancel at least 24 hours before the appointment." *

Please select at least one option.

"I understand the therapist will call my listed phone number. If I don't answer or arrive at Awaken-Zen Spa within 20 minutes of the scheduled time, the appointment will be marked as a no-show, and the $25 prepayment will be kept as a no-show fee, non-refundable." *

Please select at least one option.

I agree to pay Awaken-Zen Spa for services rendered, and if paying by card, I authorize Awaken-Zen Spa to process my payment with the card I provided. *

Awaken Zen Spa