top of page

Facial Treatment Intake Form

Please fill out the following form to help us understand your physical condition.

CLIENT INFORMATION

Date of Birth
Month
Day
Year

MEDICAL HISTORY

Do you have any of the following conditions? If yes, please select them

Ex.: Vitamins, herbal supplements, aspirin, topicals

Do you have any allergies or sensitivites?
Any recent surgery, including plastic surgery?
Do you require any special accommodations for your appointment?
Are you pregnant or trying to become pregnant?
Are you taking birth control pills?
Are you undergoing any hormone replacement therapy?

YOUR LIFESTYLE

What is your sun exposure?
Do you use sun protection (sunscreen, hats, protective clothing)?
Do you use tanning beds?
Do you smoke?
Do you drink more than 4 caffeinated beverages a day?
What is your alcohol consumption?

YOUR SKIN

YOUR SKIN CONCERNS
YOUR SKIN TYPE
YOUR SKIN CARE ROUTINE
Have you ever had an allergic reaction to any of the following?
Are you currently using products containing any of the following ingredients?
Any history of previous facials, microdermabrasion, peels or other treatments?
How does your skin heal?
Do you get bruises easily?
Have you ever used or been prescribed any acne medication?
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
What are your goals for your facial session?

Luz Spa Studio - Liability Waiver

I have read and completed this questionnaire truthfully. I understand that withholding

information or providing inaccurate details about my medical history, allergies, medications, and

skincare routines may lead to contraindications or adverse reactions to the treatments I undergo.

I agree to inform the technician of any changes in the above information.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Luz Spa Studio – Appointment Policy


• Cancel or reschedule at least 24h in advance.

• Cancellations under 24h or no-shows = $50 fee.

• Up to 15 min late is okay, but time will be deducted.

• After 15 min = no-show and fee applies.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Luz Spa Studio – Guidelines


• Please arrive without makeup or jewelry.

• No guests or children allowed during appointments, unless it's a parent/guardian for clients 15 and under.

• All services, gift cards, and product sales are final – no refunds.

• Clients under 18 must have signed consent from a parent/guardian.

• Clients under 16 must be accompanied during the session.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
I hereby grant permission to Luz Spa Studio to use photographs or video of me taken during my head spa session on social media, website, or advertisements.
bottom of page