Client Consultation Questionnaire Name* First Last Date Of Birth* MM DD YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country What is the best phone to reach you on?*What is the best email address to use for you?* Enter Email Confirm Email Emergency Contact Name* First Last Emergency Contact Phone*Referred by First Last What is the reason for your visit today?*How may we contact you? Please check all that apply.* Email Text Message Phone Call Are you under a Physician's care? If yes, please explain below.*NoYesIf Yes is checked above, please describe here.Are you allergic to tree nuts?*NoYesPlease list any allergies here.Do you wear contact lenses?*NoYesAre you pregnant or trying to become pregnant?*NoYesDo you have skin sensitivities? If yes, please describe below.*NoYesIf Yes is checked above, please describe here.Have you had skin cancer?*NoYesDo you have any metal in your body? If yes, please describe below.*NoYesIf Yes is checked above, please describe here.Please list all medications, both oral and topical.Are you currently using, or have you ever used, prescription acne or anti-aging medications or creams? If yes, please describe below.*NoYesIf you answered Yes above, please list what medication(s) and how long you have used them.Are you affected by any of the following? Check all that apply. Asthma Epilepsy Herpes Lupus Sinus Diabetes Cardiac Problems Headaches Hysterectomy Fibromyalgia Urinary Immune Disorder Eczema Hepatitis High Blood Pressure Pacemaker Skin Disorders Other, please describe below. What problems are you currently experiencing with your skin?*Which home products would you like more information on? Click all that apply. Cleanser Toner Serums Eye Cream Moisturizer What is your current home routine, AM & PM?*Please read the statements below and check the box under each statement to acknowledge.I understand the information here is to aid the skin care therapist and it is not a substitute for medical care. I understand the questions and have answered them honestly and correctly.* Acknowledge I understand that the services including facials, waxing and tinting given at The Spa 10, are for the sole purpose of skin cleansing, body and mind relaxation and rejuvenation.* Acknowledge I understand that it is imperative to tell my Esthetician about any oral or topical medications prior to any facial, waxing or other treatment services.* Acknowledge I understand that The Spa 10 and staff do not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility of the use of The Spa 10 at my own risk, and do not hold The Spa 10 or staff liable for loss, damage or injury.* Acknowledge I understand that results are personal and not guaranteed.* Acknowledge I certify that the information supplied here is correct and that I have not withheld any information that may be relevant to my treatment at The Spa 10.* Acknowledge Spa 10 has a strict 24-Hour cancellation policy. In the event of a late cancellation/no show the fee is $50. An invoice will be sent via Square. If we are able to replace your appointment with a client on our waitlist we are happy to waive the fee.* Acknowledge Yes! I would love to be added to The Spa 10’s monthly newsletter to receive beauty tips and special savings offers. Acknowledge Please note any additional information that may be of importance to your Licensed Esthetician regarding the spa treatment you may be receiving.Signature (your name submitted below will be considered as your electronic signature)* First Last Date Signed* MM DD YYYY PhoneThis field is for validation purposes and should be left unchanged.