Skip to content
Health Therapy & Beauty Center
Ft Myers Massage and Skincare Center
(239) 900-3005
12791 Kenwood Lane #1001, Fort Myers
Facebook page opens in new window
Buy Gift Cards
Facials
Waxing
Brazilian Wax
Hair Removal – Waxing
Massages
Read Our Reviews
REQUEST APPOINTMENT
Buy Gift Cards
Facials
Waxing
Brazilian Wax
Hair Removal – Waxing
Massages
Read Our Reviews
Esthetician Client Intake Form
You are here:
Home
Esthetician Client Intake Form
Save time when you arrive to our spa by completing our massage intake form before you arrive. You may also be directed to this form upon arrival if you prefer an electronic version.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Address
Address Line 1
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
Phone
*
Email
Do you prefer Text or Email?
Text
Email
Occupation
May we contact you about upcoming promotions/discounts?
Yes
No
How did you hear about us?
Allergies & Reactions
Have you had any reactions to skin care products or cosmetics?
Yes
No
If yes, please describe
Do you have any allergies?
Yes
No
If yes, please describe
Do you have any other health concerns we need to know about?
Yes
No
If yes, please describe
Skin Type & Condition
Skin Type
Normal
Oily
Dry
Combination
Areas of Concern (check all that apply)
Breakouts/Acne
Uneven Skin Tone
Excessive Oil/Shine
Dull/Dry Skin
Blackheads/Whiteheads
Sun Damage
Wrinkles/Fine Lines
Rosacea
Redness/Ruddiness
Sun/Liver/Brown Spots
Broken Capillaries
Dehydrated
Other (please specify)
When you go out into the sun do you:
Always Burn
Usually Burn
Sometimes Burn
Rarely Burn
Never Burn
Have you seen a dermatologist within the past year?
Yes
No
When dermatologist If
If yes, please explain
Do you currently use any of the following products? (check all that apply)
Accutane / Isotretinoin
Scrub/Peel
Tretinoin/Avita
Adapalene
Renova
Topical Vitamin A
Differin
Retin-A/Stieva-A
Topical Vitamin C
Other (please specify)
If yes, please describe
Have you recently received Botox, Restylane, or Collagen injections?
Yes
No
If yes, please specify
ACKNOWLEDGMENT & RELEASE
By signing this form, the client agrees to the following: | I understand, have read and completed this questionnaire truthfully and agree to inform the technician of any changes in the above information. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Signature
*
Clear Signature
Submit
Go to Top