Vegan Spa

Skin Care Questionnaire

Name:Address:

How did you hear about us ?

City:State: Zip:

Date:

Date Of Birth:

Referred by:

Phone Day: Phone Evening:Email Address:

Concerns & Interests

Current health & Lifestyle

What skin problems or concerns would you like to address?

Do you follow a home skin care regimen?

If Yes, check the items and identify the name of the products used regularly.

What would you like to change about your skin?

No

Soap Eye make up remover

Cleanser Toner/Astringent

Serum Night cream

Eye cream Day cream

Scrub/Exfoliant Sunscreen

Retir-A®/Renova® Retinol cream

AHA products(s) Benzoyl peroxide

Skin bleacher/lightener

MakeUp Brand(s)

Other, list

Yes

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List all the medications, oral and topical, you are currently using or have used in thepast six months:

Accutane® Birth ControlSteroids, topical or orally (ex: prednisone)

Antibiotics (please list) Other

Have you ever had a facial waxing or used a depilatory in the past week?

No Yes

Have you ever had a chemical peel? No Yes

If Yes, which type? Approximate date? (mo/yr)

When was the last time you exfoliated the area we will be treating today?

Do you sunbathe? How often?No Yes

Do you use a tanning booth? How often?No Yes

Do you use sunscreen regularly? SPF?No Yes

Have you had an allergic or irritant reaction to a skin care product?If Yes, please explain

No Yes

If Yes, please list all allergies

All of our ingredients contain fruits, vegetables, herbs, tree and nuts allergens.Do you have ANY food allergies? No Yes

If Yes, do you use honey?Are you vegan? No Yes

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Rejuvenating Vegan Spa offers all of our guests the option of using honey. Our honey comes from a local family owned company that has been around for over 100 years and offers pure honey that has not been over processed or altered.

Vegan Spa

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Acknowledgments and Treatment Consent

I acknowledge that Rejuvenating Vegan Spa, Inc. scope of treatment is limited to minor skin concerns, cosmetics, and aesthetically oriented services. It is in no way a sbustitute of replacement for care by a dermatologist for healthcare concerns outside of the scope defined above. I remain responsible for my own dermatology

Please check if you have any of the following health conditions:

Asthma/Hay Fever Arthritis Diabetes Cancer Heart Disease

Hepatitis Hormonal conditions Pregnancy Cold sores/fever listers

Back injuries Hip or knee replacement HIV/AIDS

When did you last see a dermatologist?How long agoyou had?

What types of skin care treaments have

If Yes. please specify:

Any known allergies to local anesthetics or medications?If Yes, please explain

No Yes

Please check if you have any of the following health conditions:

Bleeding Problems Skin Cancer Stomach Ulcer High Blood Pressure

Hives Turbeculosis X-Ray Therapy Heart Murmur Eczema

Cardiac Pacemaker Fainting Spells Other

Dermatology History

Have you had any cosmetic procedure or laser surgery in the past six months?

5 Months

2 Year

1 Year

No Yes

Vegan Spa

medical care including but not limited to conditions such as skin cancer, melanoma,psoriasis or eczema, among others. I therefore hereby release Rejuvenating Vegan Spa and all of its employees or affiliates from all responsibility in connection with the diagnosis and treatment of such skin conditions. I hereby authorize the Rejuvenating Vegan Spa for treatment of cosmetic and minor skin care. I understand that I amfinancially responsible for services. I understand that Rejuvenating Vegan Spa uses ingredients that contain fresh fruits, vegetables, herbs, nuts, seeds and honey (for guests that use honey) in all services and I have been asked about allergies above and will not hold Rejuvenating Vegan Spa liable for any reactions due to allergies and or sensitivities caused by the ingredients used in my services.

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Client’s Signature: Date:

Provider’s Signature: Date:

Please note: It is extremely important to inform us during the course of your treatment of any changes in the usage of all medications including Accutane®, Retin-A®, and other prescribed topical and oral medications. It is for your protection and safety. Thank you for answering our questions. The information in this questionnaire is strictly confidential.

Vegan Spa

To sum it up: Our Acne BootCamp is an intense 16 week program that gets to roots cause of ones acne. The only true way to get clear skin and to live a life free of acne forever. Not everyone is accepted into our program. If you or someone you know is interested in applying for our ABC program, let your esthetician know today and we will be in contact with you.

Have you heard about our Acne BootCamp?

We truly care for those suffering with acne and just as a thank you for everyone yourefer that signs up for our ABC Program you will receive a $50 gift certificate.

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No Yes

Your best contact information:Name:Email:Best Phone:Is the ABC Program for yourself or for someone you know?

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