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Please complete the Questions to the best of your knowledge. All information provided will be kept confidential and secure. This information is used to determine contraindications to product/treatment, factors that can impact skin health and to provide customized skin health program recommendations.
Full Name *
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Best E-mail Address: *
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Today's Date: *
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What Type of Skin Care Appointment did you book with us?
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What's the Date of Your Appointment:
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What Time is your Appointment: *
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Who's your Current Dermatologist?
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Cell Phone Number: *
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Address:
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City:
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State:
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Zip Code:
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Your Birthday
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Emergency Contact Name:
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Emergency Contact Number:
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What are your main skin care concerns?
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If you could wave a magic wand how would your skin look in 6 months?
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Any special requests for today? (extractions, skin soothing, skin clearing, hydration, relaxation, waxing)
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Medical, Health, Bodily Conditions: Is there anything I need to know before we get started? The more I know, the better your results. (Please List: allergies, sensitivities, pregnant, nursing, health issues, diabetic, medications, metal plates, cold sores, herpes, Retin A use or any topical products that might cause skin sensitivity).
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What did you LOVE about your first/last facial, and what could you have lived without?
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Knowing that home care is a big part of achieving beautiful skin, would you like to chat about how to maintain today's results at the end of your facial?
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What's Your Fitzpatrick Type/Number
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Have you tried a Microdermabrasion or Peel before?
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Do you want to be added to the waitlist or contacted for last minute openings? *
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Preferred form/style of contact *
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I understand by completing this form, I give Luxury Lotus Spa & Staff permission to contact me *
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I give Luxury Lotus Spa & Staff permission take pictures of me to help track my progress. I understand the pictures will not be shared with anyone else without my written consent. *
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What's Your Occupation? - Knowing what you do for a living helps us understand your daily habits, stress levels, and helps use when we are customizing your home care and professional treatments *
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How to did you find us?
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______ I understand that Luxury Lotus Spa services including facials and body treatments given at Luxury Lotus Spa are for the sole purpose of skin cleansing, body and mind relaxation, and rejuvenation. *
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______ I understand that it is imperative to tell my Esthetician about any oral or topical medications prior to any facial, waxing, spray tanning or body treatment services.
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______ I understand that Luxury Lotus Spa and staff do not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility for the use of Luxury Lotus Spa at my own risk, and do not hold Luxury Lotus Spa or staff liable for loss, damage or injury.
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______ I understand that results are personable and not guaranteed.
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______ I confirm that to the best of my knowledge that the answers given on client consultation form are correct and that I have not withheld any information that may be relevant to my treatment at Luxury Lotus Spa.
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______ I understand that I must provide at least 24 hours advance notice for the cancellation of an appointment.
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_____ I understand Luxury Lotus Spa has a strict 24-hour cancellation policy. In the event of a late cancellation/no show, the fee is $50.00-$150. An invoice will be sent via square. If we are able to replace an appointment with a client on the waitlist we are happy to waive the fee.
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_____ I understand there are risks associated with skincare treatments. Such as redness, sensitivity, peeling, inflammation. Any additional concerns I will discuss with my practitioner.
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*Please note any additional information that may be of importance to your Licensed Esthetician regarding the spa treatment you will be receiving:
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