INTAKE FORM - Confidential Skin Health Questionnaire

Today’s Date: ____________

Name: 
_______________________________________________         Date of birth:  _____________

Email address: 
______________________________________ (to receive spa specials)

Cell phone number:
___________________________________
                                                                                                      
Occupation: 
______________________________  Who referred you:  ________________________

Do you smoke?
________     H2O - How much water do you drink daily? ___________

Are you allergic to anything (latex, shellfish, aspirin)?
______________________________________________

                                                                             

Current level of stress:  1   2   3   4   5   6   7   8   9   10   (#10 is the most stressed)

Have you ever received any of the following treatments? Circle all:

Facial      Microdermabrasion      Chemical Peel     LED Light Treatment     Radio Frequency

Fillers (date): _____________   Botox (date): ___________   Cosmetic surgery: ___________________________
Laser Treatment?  IPL / Fraxel / other:
__________________________________________________________

What would you like to improve with your skin? 
_________________________________________________   __________________________________________________________________________________________
_____________________________________________________________________________________

CIRCLE ALL THAT APPLY:

Hyperpigmentation / Dark spots          Sun damage             Skin tightening             Hydration / Dry skin        Oily skin         Acne - once a month / more than once a month / all of the time           Acne scars            Reduction of redness           Rosacea         Overall texture      Reduction of fine lines: all over / eyes / mouth

What products do you currently use on your skin?

                      Brand                                               How often? AM /PM/both


Cleanser:       ​__________________________________________            ______________________                     

Exfoliate:          ​__________________________________________            ______________________   


Serums:         ​__________________________________________            ______________________


Moisturizer:
    __________________________________________            _______________________             


Sun protection:
 _________________________________________            _______________________

Other products:
 _____________________
______________________________________________
 

Do you use AHA / BHA / Retinol?  Date last used? ______________

Signature: ___________________________________________________        Date: ___________________



Name:  ________________________________  Date of last facial: _______
_____

Allergies: _______________________________


Primary concerns:
________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________

Previous treatment:  

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Plan:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Treatments:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FEEDBACK FORM

**After filling out the for please either copy and email it to Mary@premierfaceandbodywork.com or you can mail it to Premier Face and Bodywork 1209 Park Lake Street Orlando, Fl 32803. We look forward to hearing your opinion.


Would you come back to this spa in future?      Yes No

The treatment room was clean, private, and relaxing:     Yes No

The overall atmosphere of the spa was professional and relaxing:     Yes No

Your esthetician was friendly, knowledgeable, and professional:    Yes No

Your appointment started and finished on time:     Yes No

Your treatment was good value for the cost:      Yes No

Were your expectations for today’s visit met?      Yes No

Do you feel your needs and concerns were addressed?     Yes No

How did you first hear about our spa? 

________________________________________________________________________________

On a scale of 1 to 5, with 5 being the best, how was your overall experience

with us today?  1   2   3   4   5

What did you like best about the treatment you had today?
________________________________________________________________________________
________________________________________________________________________________

________________________________________________________________________________


Was there anything we could have done better/do differently for you next visit? ________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________


Do you have any questions that were not addressed? (If yes, please note):
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________


Any other comments:
________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________

Hours of operation:   Appointment only    M-SAT: 10-6pm & Sun: appt only