Facial Intake form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

*Entering your birthday allows us to personalize your experience with special deals & exclusive birthday gifts from our spa!

Address

Yes, subscribe me to your newsletter.

Intake

Skin Health

What best describes your skin when exposed to direct sunlight?

What is your skin type?

Does your skin bruise easily?

Yes

No

Other

Skin Concerns

Skin Care

Do you have a daily skincare routine?

Yes

No

What skincare products do you use?

Have you had a professional facial before?

Yes

No

Can you recall when it was?

Do you use Prescription skincare products?

Do you have any special skin problems or concerns pertaining to your face or body?

Lifestyle

Do you travel a lot?

Yes

No

Other

Do you work?

Yes

No

Other

List any sporting/club activities

Do you consume tobacco/nicotine products?

Do you any allergies( ingredients, chemicals, etc)

If there are any health issues, or medical concerns please specify below.

Are you willing to make changes in your lifestyle to keep your skin health at its best? (Keeping up with treatments, cutting out harmful foods, scheduling around physical activity, etc)

Yes

No

Other

Anything else you would like us to know?

Signature

By signing below, you agree to the following: I consent to allow "Kai Vida Face Spa" to consult with and evaluate me to determine if I am a good candidate for the facial treatment. I agree that these forms have been completed truthfully and to the best of my knowledge and abilities. I agree to terms & conditions.

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