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Inner Essence Spa LLC Case History Card
Name:___________________________________________________________ Address:_________________________________________________________ City:___________________________________ State:______ Zip:___________ Email Address:____________________________________________________ Yes, please email me information from Inner Essence Spa about special offers, new Phone (home)_________________________ (work)_____________________ (cell)______________________________________ Carrier________________ Is it okay for us to text you with appointment confirmations? Yes No Date of Birth:____________________ Marital Status:______________________ Appointment Gender Preference (please circle): No Yes ___________________ Name:___________________________________ Relationship:_______________ Phone:_____________________________ Email:__________________________ 1. Have you had a facial treatment before? No___ Yes___ 2. Are you under a dermatologist’s care? No ___ Yes ___ 3. Is your dermatologist aware you are receiving care from us? No___ Yes ___ 4. Are you using, or have you used in the past, any of the following (please circle): Azelex, Differin, Tazarac, Renova, RetinA, Accutane, AHS’s a. If yes to any, how long: _____________________________________ 5. Have you had any cosmetic surgery? No___ Yes ___ a. If yes, please state the nature of the surgery:____________________ ________________________________________________________ 6. Are you taking birth control pills? No___ Yes ___ 7. Are you taking hormone replacement therapy? No ___ Yes ___ 8. Are you taking prescription drugs? No ___ Yes ___ a. If yes, please list: _________________________________________ 9. Do you wear contact lenses? No ___ Yes ___ 10. Do you smoke? No ___ Yes ___ 11. Do you have any allergies to cosmetics, foods, and/or drugs? No___ Yes___ a. If yes, please list:__________________________________________ 12. What products do you presently use (please circle all that apply)?: Soap, Facial Cleanser, Toner, Scrub, Mask, Moisturizer, Sunscreen, Other:_____________________________ 13. Are you affected by or have any of the following (please circle all that apply)?: Skin Diseases, Herpes Simplex, Asthma, Epilepsy, Diabetes, Cardiac Problems, Pacemaker, Metal Pins or Implants, Pregnancy, Other Concerns:____________________________________________________ Inner Essence Spa LLC is not responsible for the aggravation of conditions, which were present, but not disclosed to the practitioner, at the time of service received and which may be affected by the service. Inner Essence Spa LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. By signing, you are stating that you fully understand the above questions and authorize treatment. Thank you. Your Signature:____________________________________Date:______________ How did you hear about Inner Essence Spa & Wellness Center? ___________________________________________________________________

Source: http://www.inneressencespa.com/Content/forms/Inner%20Essence%20Spa%20LLC%20Case%20History%20Card.pdf