Copyright 2010: G'nique's Spa Services | Brazilian Waxing. All Rights Reserved.
Facials, Massage, & Body Work Intake Form
By completing this form online it saves you time when you come in for your initial apppointment. if you prefer to fill out the paper work during your appointment please arrive 20 minutes early. The information you provide on this intake form is confidential.  We do not share information with any third parties.  We use this information to help give you the best result during your visits with us.  When you arrive  you will be asked to sign the printed version of this form. Your information is reviewed so that the appropriate services and products will be used. Please be as accurate as possible and help us give you the results you really want.
Name (First & Last):
Address:
Email Address:
Emergency contact :

Sex:
List  any medications, supplements, vitamins that you have taken:
Age:
Telephone #:
Emergency Telephone Number:
(Please list home and Cell)
How did you hear about us?:
Birthday:
Occupation:
Please list any  skin conditions
(Acne, Eczema, Skin Cancers, Rosacea, Mycosis (fungal infection), Contact Dermatitis, Skin Allergies, Skin Rashes, Athletes Foot, Dandruff, etc.
Are you currently taking an oral contraceptive?
Have you had any major or minor surgeries?
Please list surgeries:
Are you pregnant or trying to become pregnant?
Are you currently on your menstrual cycle?
What skin Care products are you currently using?
How much water do you consume daily (Cups)?
Do you ever experience oilyness or shine during the day?
Do you ever experience skin breakouts?
Have you ever had a massage?
What massage pressure do you prefer?
What results do you want from your massage session(s)?
What skin care goals do you have for yourself?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Light
Medium
Firm
Relaxation
Pain Relief