Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Spa Policy Acknowledgement *

I have read and agree to the Terms and Conditions of Spa 180's Policies.

Name *

First Name

Last Name

What skin care products are you using at home on your FACE? *

Check all that apply.

Soap

Cleanser

Toner

Moisturizer

Serum

Masque

Exfoliants

Eye Products

What products are you using on your BODY?

Check all that apply.

Soap

Shower Gel

Scrubs

Oil

Body Lotion

Depilatories

Self-Tanner

Skin History

Check if you have had any of the following:

Chemical Peels

Microdermabrasion

Resurfacing

Facial Cosmetic Surgery

Skin Type *

Check the one that BEST describes your skin.

I- FAIR (always burns, never tans)

II- MEDIUM-FAIR (usually burns, difficulty tanning)

III- MEDIUM (tans about average)

IV- MEDIUM-DARK (tans easily, burns sometimes)

V- DARK (brown skin, only tans)

VI- VERY DARK (black skin, never burns)

Oil Secretion

Check the statements that are TRUE for your skin.

I experience oily shine throughout the day.

I experience skin breakouts.

Capillary Activity

Check the statements that are TRUE for your skin.

I blush easily when nervous.

I have a tendency to redness in my face.

I suffer from sinus problems.

Nerve Activity

Check the statements that are TRUE for your skin.

I drink 4 or more caffeinated drinks per day.

My skin frequently itches or burns.

I am claustrophobic.

Skin Reactivity

Check any of the following that has caused a reaction in your skin.

Cosmetics

Medicines

Iodine

Fragrance

Pollen

Food

Hydroxy Acids

Sunscreens

Other (if other, please comment in Notes at the bottom of this form)

Moisture Hydration *

Do you ever experience these conditions?

Tightness

Flakiness

Obvious Dryness

None of the above

General Health

Check all that apply.

I am a smoker.

I exercise regularly.

I follow a restricted diet.

I wear contact lenses.

I have metal implants, a pacemaker, or body piercings.

Female Clients ONLY

Check all that apply to you.

I use birth control pills.

I have an IUD.

I am pregnant.

I am lactating.

None of the above apply to me.

Male Clients ONLY

Check all that apply to you.

I use an electric razor.

I prefer a wet shave.

Shaving irritates my skin.

I am prone to ingrown hairs.

None of the above apply to me.