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The Mom Spa
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Home
About
New Client Forms
Skin Care Intake
Massage Intake
Permanent Makeup Intake & Consent
Memberships
Services
The Mom Spa
Massage
Permanent Cosmetics
Skin Care
Makeup & Lashes
Blog
Book Now
Facials, Waxing, Lashes and More
Name
*
Name
First Name
Last Name
Email Address
*
Phone
*
Date of Birth
Occupation
Address
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about us?
*
Skin Type
Normal
Oily
Dry
Combination
Current Skin Conditions
Rosacea
Sun Damage
Uneven Skin Tone
Texture
Acne/Breakouts
Excessive Oil/Shine
Broken Capillaries
Blackheads/Whiteheads
Wrinkles/Fine Lines
Redness/Ruddiness
Dull/Dry Skin
Dehydrated
Sun/Liver/Brown Spots
Acne Scarring
Conditions you are currently experiencing
Please select all that apply
Headache
Inflammation
Muscle Cramps
Anxiety
Fatigue
Insomnia
Stress
Forgetfulness
Which aroma(s) do you prefer?
Please select all that apply
Lavendar
Citrus
Peppermint
Lemongrass
Eucalyptus
Are you currently pregnant or nursing?
Yes
No
Are you under the care of a Dermatologist
Yes
No
Known Allergies
*
This may include cosmetics, AHAs, Fragrance, Latex, Sunscreen, etc
Are you currently or have you used any Retinol/ Vitamin A derivative products within the last 3 months
If yes, please specify
Have you recieved any type of cosmetic injection in the last 6 months
If yes, please specify:
Signature
*
Signature
By Signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and Age Later Aesthetics for any injury or damages incurred due to any misrepresentation of my health history.
First Name
Last Name
Date
Date
MM
DD
YYYY
Thank you!