Face and Body Form

Name*

Address*

Street Address Address Line 2 City Province Postal Code

Email*

Mobile Phone

Home Phone

Birthday

Occupation

How did you hear about us?

Your Health

Within the last year, have you been under doctor’s care (ie: physician, dermatologist, ND….)?*

Yes
No

Please Specify*

Have you had any major health problems in the past or present?

Yes
No

Please Specify*

List any medications, supplements or vitamins taken regularly

Do You Smoke?*

Yes
No

Do you exercise regularly?*

Yes
No

Do you follow a restricted diet?*

Yes
No

Please Specify

Have you experienced claustrophobia?*

Yes
No

Surgery in the past year?*

Yes
No

Please Specify

Major injuries in the past year?*

Yes
No

Please Specify

Do you suffer from allergies?*

Yes
No

Please Specify

Do you suffer from skin conditions?*

Yes
No

Please Specify

Rate your stress level on a scale of 1 to 5*

(1=low, 5=high)

Massage Pressure Preferred

Declaration

Acknowledgement*

I agree

I am aware that any massage services at Spa Zone are provided by an esthetician or skin care therapist and is NOT registered massage therapy (or deep tissue therapy).

Date*

Signature*

**I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician or therapist if my current medical or health conditions and to update this history form. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

Skin Care

Check all that apply

I sunbathe or use tanning beds
I have any metal implants, body piercings or a pacemaker
I drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)
I suffer from sinus problems
I have a tendency to redness
I burn easily in moderate sunlight
I have experienced burning, itching or stinging sensations on my skin
I have had chemical peels, microdermabrasion or any resurfacing treatment in the past
I have had chemical peels, microdermabrasion or any resurfacing treatments in the past month

Were you happy with the results & why?

What SPF sunscreen do you use on your face?

What SPF sunscreen do you use on your body?

Do you currently use products that contain the following ingredients? Check all that apply.

Glycolic Acid
Lactic Acid
Exfoliating Scrubs
Hydroxy Acid
Vit A derivatives

Do you use any prescription skin products (ie. RetinA, Adapalene, etc)?

Yes
No

What body care products do you currently use?

Soap
gel/cream cleanser
scrub
cream
oil
depilatory products
self tanner

Details?

What facial skin care products are you currently using?

Soap
cleanser
toner
serums
masque
exfoliator
eye product
night treatment
moisturiser

Details?

What are your specific skin concerns or challenges?

What are your skin goals?

CAPTCHA

Your Health

Declaration

Skin Care

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Spa Zone Hours

Spa Zone Location

Contact Spa Zone

Methods of Payment