Facial Intake Form

Instructions

Please read carefully and answer to the best of your knowledge. If you have any questions please contact us by online support chat

How did you heard about us? *
Where do you regularly look for new businesses and offers? *
Will you use a Groupon voucher?

You can find it near the bar code

Personal Information

Minor Release Form

All persons under the age of 18 are required to have a parent or guardian fill out this form. By signing below you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s).We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor.You also agree that you have completed the Intake Form and have informed the therapist of any and all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).
SIGNATURE OF PARENT
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Covid-19 Liability Release Waiver

**Signature Required During Check-in**
Due to the outbreak of the novel Coronavirus (COVID-19), Lifetime Laser is doing everything we can to protect you, our clients, our community and our staff. To this extent, Taleon LLC dba Ananda Spa, referred in this document as “Ananda Spa” will be following the Center of Disease-Control (CDC)
with regard to social distancing practices and sanitation. We ask that our clients disclose their health history and continue to implement these sanitation and disinfection procedures.
Symptoms of COVID-19 include:
  • Fever
  • Fatique
  • Dry Cough
  • Difficulty Breathing
1. I agree to the following: *
Ananda Spa is following these enhanced procedures to prevent the spread of the Coronavirus (COVID-19)
  • All clients must wear a facial mask during their staying within the business premises or service will
    be denied
  • A maximum of 5 customers will be allowed in the salon
  • We discourage guests accompanying scheduled customers.
  • Additional time will be scheduled in between client appointments to limit client contact.
  • Each client is required to wash their hands upon arrival and before departure.
  • All Skin care technicians will thoroughly clean customers’ hands before service
  • All equipment used during treatment will be cleaned, sterilized, and disinfected
  • All surfaces will be thoroughly cleaned with hospital grade disinfectant before and after each client, according to the manufacturer’s directions.
By signing below, I hereby release and agree to hold Ananda Spa harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation for damages or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in
any way in connection with any services received from Ananda Spa. I agree to release Ananda Spa from any and all liability for the unintentional exposure or harm due to the Coronavirus (COVID-19)
SIGNATURE OF CLIENT
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Health History

1. Do you wear contact lenses?
2. Have you had any surgery?
3. Please check is you are presently experiencing or have experienced any of the following:
4. Do you have any condition that could affect service options, such as arthritis, allergies, diabetes, or other circulation disorders, heart problems, high blood pressure, sensitivity to heat or any cosmetic ingredients, taking any medications such as blood thinners, etc.?
5. Do you have food allergies?
6. Latex allergies?
7. Any other allergies?
8. Are you currently taking any prescription    medications?
9. Are you currently pregnant or undergoing     fertility treatments?
10. Is there anything your technician should       be aware of before your treatment?
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Skin Care History

11. Primary reason for your appointment today
12. How often do you receive facials?
13. How often do you receive body treatments?
14. Have you ever had an adverse reaction to a cosmetic product?
15. Special concerns you have about your skin:
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Home Care

16. Normal skin routine
17. What skin care products are you currently using at home:
18. Do you take nutritional supplements?
19. Do you exercise?
20. Do you have a tendency to scar?
21. Do you feel your skin is sensitive?
22. We want to show you how your skin is improving as you keep getting treatments with us, so we might document your treatment progress with pictures and/or videos:
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In consideration for receiving Ananda Spa services, I hereby release, waive, discharge, and covenant not to sue Ananda Spa, it’s owners, officers, agents, servants, and employees from any and all liability, claims, demands, actions, and causes of action related to any loss, damage, or injury that may be sustained by me or property belonging to me, whether caused by negligence or otherwise, while participating in such activity or while on the Ananda Spa premises, and this waiver and release shall bind the members of my family and any current or future spouse or domestic partner if I am alive, as well as my estate, family, heirs, administrators, personal representatives or assigns if I am deceased. I am fully aware of the risks involved and hazards connected with spa treatment, and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in such an activity, whether caused by the negligence or otherwise.
SIGNATURE OF CLIENT
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