CONTACT SACRED SKIN Send a Text858-945-7147 Send an Emailsacredskinsd@gmail.com Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Cell Phone * (###) ### #### Gender * Female Male How did you hear about Sacred Skin San Diego? * What is your Facebook and/or Instagram Handle? Would you like the 60, 90 or 120 min Sacred Ritual? * If choosing 90 or 120 min Sacred Ritual, what Add-On(s) would you like? * Choose One for 90 min or Choose Two for 120 min: a) Back Scrub Exfoliant with Reiki Infused Jade & Basalt Hot Stone Massage b) BT Micro Ultrasonic Face Scrubber and Hydrojelly Mask with Facial Ice Globe Massage c) Celluma LED Light with Sound Bath d) Hydrojelly Mask and Facial Reflexology Massage with Reiki Infused Gua Sha e) Hydrojelly Mask and Facial Reflexology with Facial Cupping f) Hands and Arms Scrub Exfoliant with Reiki Infused Jade & Basalt Hot Stone Massage g) High Frequency Facial and Hair Treatment with Hydrojelly Mask h) Oxygen Pod Infusion i) Reconstructive Facial Massage j) Reiki and Crystal Healing with Sound Bath k) I'm choosing the 60 min Sacred Ritual (No Add-Ons) Would you like your Service on a Weekday or Weekend/AM, MID, or PM? * I Would Like To... Purchase a Sacred Skin San Diego Gift Card Thank You - Sacred Skin Team will get back to you shortly! ALL NEW CLIENTS MUST FILL OUT INTAKE FORM WITHIN 72 HOURS OF BOOKING A SERVICETHANK YOU! CLIENT INTAKE FORM Client Intake Form Today's Date * MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Cell Phone * (###) ### #### Emergency Contact Name * First Name Last Name Emergency Contact Number * (###) ### #### How did you hear about Sacred Skin San Diego? * Birthday * MM DD YYYY Gender * Female Male Facebook and/or Instagram Handle Spa Wrap Size * S/M L/XL 2XL/3XL Which Aromas(s) do you prefer? * please select all that apply Lavender Lemon Citrus Peppermint Eucalyptus Frankincense Other None Do you prefer lavender infused warm/cool facial towels (facial towels soaked with drops of lavender essential oil and water)? * Yes No, I prefer warm/cool facial towels only (towels soaked in water only). Are you sensitive to heat/steam? * *Please type YES or NO List of known allergies * *Please type NONE if you have no allergies Are you sensitive to the following? * *please check that all apply Asprin Caffeine Fragrance Fruits Gluten Nuts Natural Rubber (Latex) Preservatives Milk Shellfish None Other If you checked any boxes (above), please explain if it's topical, ingested, or both topical and ingested? * *If you do not have any sensitivities, please type NO SENSITIVITIES List of topical prescriptions/medications/topical * *Please type NONE if you are not taking topical prescriptions/medications/topical I understand and agree to consult with my physician first if I am currently taking prescriptions/medications/topical as it may increase sensitivity and/or adverse reactions from the skin products I will receive during my facial. * I understand and agree Do you have any skin conditions? * Yes No If yes, explain *List and explain skin conditions List of supplements * *Please type NONE if you are not taking any supplements What skin type do you think you have? * Dry Normal Combination Skin Oily Unsure Do you consider your skin: * Sensitive Resilient Unsure What area(s) of concerns do you have regarding your skin? * Breakouts/Acne Excessive Oil/Shine Broken Capillaries Blackheads/Whiteheads Wrinkles/Fine Lines Redness/Ruddiness Uneven Skin Tone Rough Texture Dull/Dry Skin Dehydrated Sun Damage Rosacea Sun, Liver, and/or Brown Spots Acne Scarring Clogged Pores NONE When you go out in the sun, do you: * Never burn Very rarely burn Sometimes burn Usually burn Always burn Do you tan in sunbeds? * Yes No How's your stress level? * Your stress level can play a big part in your skin and overall health. 0 (NO STRESS) 1 (LOW) 2 3 4 5 (HIGH) Do you smoke cigarettes? * Yes No Do you suffer from cold sores or any other viral infections? * Yes No If yes, when was your last outbreak (cold sores or any other viral infections)? Skin goals * Most recent facial/treatment/procedure * *Please type N/A if you haven't had any recent facial/treatment/procedure Prior reactions to skincare, cosmetics, treatments, facials, etc * *Please type NONE if you haven't had any reactions to skincare, cosmetics, treatments, facials, etc How many hours do you sleep on average per night? * Have you been under the care of a dermatologist within the past year? If yes, provide information to help avoid any irritation/sensitivities/adverse reactions during your facial. * *Please type NO if you haven't been to a dermatologist within the past year What skincare products are you using? * *Please type NONE if you are not using any skincare products Are you pregnant? * *Sacred Skin San Diego offers pregnancy safe products but please consult with your physician first Yes and I agree to receive approval from my physician first before booking a facial No If you are currently pregnant, how far along (in weeks) are you? If you are pregnant, any high risk factors? * Yes No I am not pregnant If yes, please explain. Pregnancy high risk factors Are you nursing (breastfeeding/pumping)? * *Sacred Skin San Diego offers safe products for nursing mothers but please consult with your physician first Yes No I am not pregnant Medical History * please check all that apply Accutane *if taking accutane within a year, please consult your physician before receiving a facial Arthritis Epilepsy Fever Blisters HIV Lupus Plastic Surgery Psoriasis Vitamins Rashes Warts Acne Depression Diabetic Eczema Hepatitis Insomnia Pregnant Seborrhea Shingles Allergies Metals in Body Heart Condition/Pacemaker Blood Pressure Pigmentation Thyroid Medications Planning on Pregnancy Skin Cancer Surgeries NONE Personal Skin Care History * please check all that apply Eye Make-up Remover Facial Cleanser Toner Exfoliation Mask Serum Eye Cream Neck Cream Retinol Moisturizer Facial Sunscreen/SPF Body Sunscreen/SPF Lip Treatment Body Wash Body Scrub Body Mask Cold Roller Gua Sha Reflexology Facial/Body Massage NONE Have you used Retin-A, Renova, Retinol, AHAs (adapalene hydroxyl acid) in the last 15 days? * Yes No If yes, when was your last application? I understand and agree to stop any at home facial treatments and skin care products with active ingredients such as salicylic acid, glycolic acid and retinol for at least 72 hours prior to my facial appointment * *applying active ingredients within 72 hours of your facial can cause irritation and/or adverse reactions I understand and agree I understand and agree to avoid waxing 48 hours before my facial appointment as it could lead to irritation * I understand and agree Have you had any treatments, chemical peels, lasers, and/or injectables (BOTOX and dermal filler) in the last 30 days? * *Depending on your physician and how recent your procedure was will determine whether you need to reschedule your facial Yes No If yes, what and when was your last application (treatments, chemical peels, lasers, injectables/BOTOX, and/or dermal filler) I understand and agree that I need to wait 2 weeks to receive a facial before my last injectables/BOTOX application * Please consult with your physician first I understand and agree I understand and agree that I need to wait 1 month to receive a facial before my last FILLER injectable, microneedling, and chemical peels * Please consult with your physician first I understand and agree Have you recently had permanent makeup and/or microblading? If so, when? * *Please type N/A if you haven't had permanent makeup and/or microblading I understand and agree that I need to wait 4 weeks to receive a facial after AND before permanent makeup and/or microblading * I agree Have you been sick recently? * Yes No If yes, please tell me what you were ill with, and how long you have been symptom free? Additional Questions or Special Info you would like to share Add-On: BT Micro Utrasonic Scrubber * Bio-Therapeutic ultrasonic scrubber releases ultrasonic waves assisting in removal of dead skin cells and smoothing textures to even tones. Contraindications: Pacemaker or other implanted electrical device Cancer Epilepsy Pregnancy Any contagious or transmittable diseases Hemophilia or other bleeding disorders Do not use on broken or damaged skin Consult a Physician before using if there are any health or medical concerns I read the list of the following contraindications and does not affect me. I did not choose the Add-On: BT Micro Ultrasonic Face Scrubber Add-On: Celluma LED Light * Emits blue, red, and near-infrared wavelengths that promote anti-aging for the face, acne removal, wound & scar healing while decreasing pain & inflammation Contraindications: Do not use if you're pregnant or breastfeeding, history of seizures and epilepsy, if taking cortisone injections or any other kind of steroid injections, and if using photosensitive drugs. I read the list of the following contraindications and does not affect me. I did not choose the Add-On: Celluma LED Light Add-On: High Frequency Facial and Hair Treatment * High Frequency glass electrode applied on the face and scalp that kills acne causing bacteria, promote blood circulation, exfoliation of dead skin cells, treats dandruff and hair thinning. Contraindications: Pacemaker or other implanted electrical device Pregnancy I read the list of the following contraindications and does not affect me. I did not choose the Add-On: High Frequency Facial and Hair Treatment I have completed this form to the best of my ability and knowledge and agree to inform Michelle Esperon Santos or Sacred Skin San Diego of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform Michelle Esperon Santos or Sacred Skin San Diego of any discomfort I may experience at any time during my treatment to allow her to adjust accordingly. I agree to waive all liabilities toward Michelle Esperon Santos or Sacred Skin San Diego for any injury or damages incurred due to any misrepresentation of my health history. I also agree that I will not hold Michelle Esperon Santos or Sacred Skin San Diego accountable for any choices I make as a result of any service provided through www.sacredskinsandiego.com, it's associated email account and cell phone number or any of it's social media accounts. By scheduling and/or paying for any session, I also attest to (a) being at least 18+ years of age (b) i understand that reiki energy & sound healing sessions are intended to promote relaxation and stress reduction and are not to take the place of medical procedures or the advice of a licensed medical professional. . * E-SIGNATURE REQUIRED: Thank You and Can’t wait to see you soon!We will remind you of your service about 3 days prior via email / text .Should you need anything prior, please don’t hesitate to reach out via email and we will get back to you as soon as possible. Cydney, RMT SACRED SKIN SCHEDULING COORDINATOR Laura, RMT SACRED SKIN EVENT COORDINATOR
