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Bella Fiore Organic Med Spa:
New Client Intake Form

New Client Intake Form

 

July 4, 2020

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Occupation: *

Referred By: *
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Occupation: *

Referred By: *
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Occupation: *

Referred By: *
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Occupation: *

Referred By: *
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Occupation: *

Referred By: *
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Occupation: *

Referred By: *
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Occupation: *

Referred By: *
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Occupation: *

Referred By: *
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Occupation: *

Referred By: *
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Occupation: *

Referred By: *
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical Information

Please List Any:


Current medications/supplements:

Allergies (topical or internal)
Have you had a family history of skin disease?*

If Yes, Type:

Please list any conditions or illnesses: *
What are your areas of concern?
Breakouts
Broken capillaries
Cystic Acne
Dehydration
Dullness
Enlarged Pores
Excessive Oil
Loss of Elasticity
Redness
Rosacea
Scarring
Sensitivity
Sun Damage / Sun Spots
Uneven Skin Tone
Unwanted Hair
Wrinkles / Fine Lines
Other

If Other, please list:
Are you using Retin-a, Renova, or Accutane (an oral form of Retin-a)?*
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?*
Are you using any other skin thinning products and/or drugs?*
Are you currently taking any antibiotics?*

I understand (even though I may not be getting waxed today) that waxing may have certain side effects such as skin removal, redness, swelling, tenderness, or other complications.

I Understand

I do not have any open lesions or active herpes outbreak, oral or genital, if applicable to the area being treated. (Please understand that active cold sores are contraindicated for any light-based devices.)

I Agree

I have stated all medical conditions that I am aware of and all medications I am taking and will update any changes in my health status

Additional Information
Have you previously undergone:
Facials
Peels
Microdermabrasion
Injectables
In the Sun do you-*
Your Sun Exposure:*
Do you use a tanning bed?*
No
Yes

If yes how often?

Current skincare routine:
Treatment Information

For Women:

Are you pregnant?*
Please read through these contraindications for our Microcurrent Facial and select any that apply to you now: *
Metal implants
Pregnancy
Epilepsy
Cancer (must be cancer free for these treatments)
Thrombosis
Active infection
Phlebitis
None of the Above

Please initial to show you have read the above:

I Agree

I understand, have read and completed this questionnaire truthfully. I agree this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin or negative effects on the body from treatments received. The treatments I receive here are voluntary and I release this institution, skin care professionals and/or massage therapists from liability and I assume full responsibility thereof. 

I Agree
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Occupation: *

Referred By: *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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