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Haven Medi-Spa Health Waiver

Please take the time to fill out and submit this online waiver prior to your appointment to confirm that you are a candidate for your desired treatment and to ensure that we are treating you as safely as possible throughout

Facial & Skincare Intake Form*

Please fill out the following form to ensure that you are being treated accordingly

First name

Last name

Date of Birth

Phone

Email

Female

Male

NB

Street Address

City

Province

Street Address Line 2

Postal Code

Emergency Contact

Emergency Contact #

How did you hear about us?

Medical History

Do you have or have you had any of the following conditions? If yes, please select them:

List A

Acne

Anxiety/Depression

Arthritis

Asthma

Autoimmune disorders

Blood disorder

Current or history of cancer

Diabetes

Eczema

Epilepsy

Headaches

Heart condition

Fever blisters

Pacemaker

Rosacea

Psoriasis

Prone to cold sores

Skin sensitivities

Thyroid conditions

List B

Herpes

Hepatitis

High blood pressure

HIV/AIDS

Hyper pigmentation

Hypo pigmentation

Hysterectomy

Insomnia

Keloid scarring

Low blood pressure

Lupus

Metal bone pins/plates

Phlebitis, blood clots

Seizure disorder

Skin disease/lesions

Seborrhea

Varicose veins

Warts

Any other condition:

Any known allergies?

No

Yes

List known allergies

List any medications you take regularly, including vitamins, herbal supplements, aspirin:

Any recent surgery, including plastic surgery?

No

Yes

Please explain surgeries

Have you ever had a facial treatment before?

No

Yes

If yes to facial treatment, please explain

Are you pregnant or trying to become pregnant?

No

Yes

Have you tanned recently?

No

Yes

What would you like to achieve from your treatment today?

Do you have any existing or recent illnesses/medical conditions that may impair skin healing?

Skincare

Please check current products you use:

Eye Make-Up Remover

Eye Cream

Mask

Cleansing Cream

Day Cream

Facial Scrub

Facial Soap

Night Cream

Exfoliants

Skin Toner/ Astringent

Neck lotion

Body Lotion

Body Soap

Hand cream

Body Scrub

Skin Concerns

Please check skin problems you might have:

Acne

Blackheads

Broken Capillaries

Comedones

Cherry Angioma

Discoloration

Milia

Oily Skin

Psoriasis

Redness

Rosacea

Scarring

Sensitivity

Sun Damage

Thin Skin

Unwanted Hair

Skin History

What is your skin type?

Your exposure to the sun?

What type of foundation do you wear?

How does your skin heal?

Do you get bruises easily?

Other skincare concerns:

Have you ever used acne medication?

No

Yes

If yes, when?

Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?

No

Yes

Have you received Botox, Restylane, or Collagen injections in the last 6 months?

No

Yes

Which drug?

If yes, please describe.

If yes, please describe.

Please note that all information provided above will be held in strict confidentiality. All information will be used by service provider to ensure quality and safety of clients.

By signing below, you agree to the following:

I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition/s that would make the requested
treatment unsuitable. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health.

Client Name (signature)

I declare that the info I’ve provided is accurate & complete

Date

Thanks for submitting!

Contact us if you have any questions about what we do or how we do it

First name

Last name

Email

Phone

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