Client Information Form printable pdf download

Client Information Form

Welcome to OM Spa! Please take a moment to fill out the following form. All

information is confidential and is used to customize your treatments and the

professional recommendations we provide for you!

Personal Information

Name:___________________________________

Date:_____________________________________

Address:____________________________________________

City:_____________________________

Postal Code:__________________ Home Phone:_______________ Business

Phone:_____________

Cell Phone:___________________ Date of Birth:______________

Email:______________________

How did you hear about OM Spa?_________________________

Skin Background

Have you had a facial before?

Y / N

Do you wear contact lenses

Y / N

How would you describe your overall skin condition?

Which part of your body holds the most stress?

What are your likes and dislikes about facials?

What is the reason for your visit today?

If you could change one thing about your skin what would it be?

What products are you currently using?

Cleanser

Toner

Serum

Moisturizer

Other

List any advanced skin care treatments you have had (microdermabrasion, skin

peels, retinol, laser treatment, acutance, fillers, Botox, etc?)

Medical History

Are you Pregnant?

When are you due?

Client Information Form