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HomeGrown Spa
2219 Rumson Road
Raleigh, NC 27610
919-412-6440

Please answer the following questions completely in order to achieve your goals safely.

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
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*

Confirm Email*
Check this box to be added to HomeGrown Spa's email list and receive education and sales updates.
Personal Information

What are your goals for your visit to HomeGrown Spa? *

Please list all health conditions for which you are seeing a physician *

Please list all prescribed medications, supplements, or OTC products. *

Please list any current or past skin cancers, the location and year. *

Are you currently under the care of a Dermatologist? If yes, please describe the issue.

Please list all brands and product names of any skin care you use, whether daily or occasionally. Please list Cleanser, Toner, Serums, Sunscreen, Moisturizer, Mask, and Exfoliation:
Have you ever had, or do you have any of the following (check all that apply)
Cancer
Seizures/Neurological Disorders
Heart Condition
Wound that would not heal
Thyroid Condition
Rosacea
Psoriasis
Eczema
Diabetes
Keloid Scarring (thick or raised scars from cuts or burns?)
Blood clotting abnormalities
Skin Cancer (if yes, describe below)
High or Low Blood Pressure
Cold sores or fever blisters of the mouth, lip or nose
Chronic Inflammatory Skin Disease
Hormon Imbalance
Bruise easily
Phlebitis, blood clots, poor circulation
Thrombosis
Epilepsy
Allergy to Stainless Steel
Deep Vein Thrombosis
Lupus
Metal bone pins or plates
Herpes

Describe your issue:
Describe your stress level:
Low Stress
Medium Stress
High Stress
Daily intake of Water
Describe your alcohol consumption:
For Women:
I have normal monthly periods
I have irregular periods
I am peri-menopausal
I am menopausal
Excessive facial hair
Tender breasts
Migraines
PCOS/Cystic ovaries
Current or past fertility treatments
Hormone replacement therapy
Birth control pills (past or present)
IUD
Hormonal injections/Pellets/Implants
Trying to conceive
Breast feeding or lactating
Which best describes your skin when exposed to the sun without sun screen?
Always burns easily, never tans (Creamy complexion)
Always burns, tans slightly (Light Complexion)
Burns moderately, tans gradually (Light/Matte Complexion)
Seldom burns, always tans well (Matte Complexion)
Rarely burns, deeply tans (Brown Complexion)
Never burns, deeply pigmented (Dark Brown Complexion)
Sunscreen use:
I spend more time outdoors than indoors
I always use sunscreen
I use sunscreen when necessary
I use mineral sunscreen
I use chemical sunscreen
Skin Condition: Check all that apply
Dry (lacking oil)
Oily
Dehydrated (lacking water)
Scaly or flaky
Hyperpigmented/Dark spots
Hypopigmentation (lightening of the skin)
Melasma
Sun Damage
Uneven texture, bumpy, rough to touch
Uneven tone/color
Enlarged pores
Sagging or volume loss
Thin
Loss of elasticity
Wrinkles
Broken capillaries
Rosacea
Acne
Ruddy/flushed/red
Congested/dull/thick feeling
Long lasting dark or pink spots after healing
Skin treatments (past and current)
Botox (anywhere)
Fillers (anywhere)
Needling
Microdermabrasion
Laser
IPL
Radio Frequency
Dermaplaning
Light Therapy
Chemical Peel
Mesotherapy
Complete or partial face/chin/neck lift
Eye/eyebrow lift or correction
Rhinoplasty
Use(d) Accutane
Any known allergies?
Asprin
Tree nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances/Essential Oils
Other
None

If Other, please describe below:
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash/Itching/Redness
Irritation
Peeling
Sun Sensitivity
Breakout
Itching
Have you taken Accutane in the past 2 years?*
No
Yes

Have you ever experienced claustrophobia?

Do you suffer from sinus problems?

Are you a smoker?

Do you have eyelash extensions, piercings or anything that should be avoided during your facial? Please note: If you wear thick mascara, please remove before your facial for a better experience.

Are you sensitive to smells (essential oils, etc.)

Have you used a tanning bed in the past? If yes, please note the last use and describe the frequency (weekly, monthly, yearly, rarely)
Do you have a pacemaker?*
No
Yes

If you have questions or concerns that have not been addressed, please describe it here:
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 Signature*
Electronic Signature Consent*
 I have read, understand, and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it may supersede any previous written or verbal consent. I understand that withholding information, providing misinformation and/or non-compliance, may result in contraindications, complications, and/or irritation to the skin. I am aware that it is my responsibility to advise the aesthetician of my current medical and health conditions and to update her with any new conditions, treatments received elsewhere, and changes in health and in medications. All information is kept strictly confidential. Your privacy is respected. Nothing will ever be sold, shared or distributed. The treatments I receive, and purchases I make from HomeGrown Spa are voluntary, and I release this institution from any liability and assume full responsibility thereof. 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. 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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