Please complete the intake form at least 48 hours prior to your first appointment. All information, health, intake forms, and emails are kept strictly confidential. We are excited to welcome you soon! Today's date * MM DD YYYY Name * First Name Last Name Email * used for appointment confirmation and reminders Phone (###) ### #### Birthday MM DD YYYY Have you ever had an intra-oral/buccal facial massage before? * Yes No How did you hear about us? * Please check what you hope to improve with Buccal Facial Massage: Wrinkles around mouth Puffy/dark/swollen circles under eyes Nasolabial folds Deep wrinkles Puffy/swollen face Dull complexion Sagging jowels Headaches Teeth clenching/grinding Sinus congestion/pain TMJ pain Have you experienced any of the following? * Botox/Dysport (within 3 weeks) Fillers (within 4 weeks) Permanent makeup/tattoos (within 4 weeks) Chemical peels (within 3 weeks) Microneedling/microblading (within 2 weeks) IPL/Laser skin treatment on face/chest/neck (within 2 weeks) Mesothrerads/thread lifting (within last 3 months) Other injectables/subdermal treatments None of the mentioned If you have had other injectables within the last 4 weeks please let us know below: Do you have any allergies or sensitivities? * Yes No If you have any allergies or sensitivities please list them below: Please check off if you have any of the followig: Please note that we do not perform the Buccal Facial if you have active acne/rosacea/eczema/psoriasis on the face below the forehead, or if you currently have a cold sore. Asthma Auto immune issues Acne Anxiety Cold sores Cardiac issues Dental implants Epilepsy Eczema HIV/AIDS Hormonal issues Lymphatic issues Metal pins/plates Migraines Pacemaker PsoriasisRosacea Sinus issues Thyroid issues TMJ pain If you have any other medical/dental/chronic conditions we should be aware of, please list them below: Are you in your first trimester of pregnancy? * Please note we do not perform any facial treatments in the first trimester of pregnancy Yes No Any serious illness/surgeries/major accidents in the last 12 months (please include dates): Are you currently under the care of a physician for any medical issues? * Yes No If you are currently under the care of a physician, please elaborate: Are you currently under the care of a dermatologist? * Yes No If you are currently under the care of a dermatologist, please elaborate: Please briefly describe your current skincare routine and include any topical prescription medications you might be using: Please describe your stress level: What are your skin concerns and goals? * What are your main goals from the Buccal Facial Massage? Relaxation Pain relief Stress reducation Healthier skin Wrinkle reduction More definition More self care Consent to receive services: * I hereby request and consent to the services of Anastasia's Beautyland Vancouver Facial Rejuvenation Spa. I confirm that the above information that I provided is correct and as up to date as possible. I've disclosed all allergies, surgeries, and health conditions that I am aware of. I acknowledge that a facial is not a substitute to medical care, medical examination, or diagnosis. I will fully indemnify and hold harmless Anastasia's Beautyland Vancouver Facial Rejuvenation Spa, affiliates, subsidiaries, representatives, agents, staff, and supplies, from and against all liabilities, claims, expenses, damages, and losses, including legal fees, arising out of or in connection with the spa treatments, services or facilities. I understand that although Anastasia's Beautyland Vancouver Facial Rejuvenation Spa uses quality products it's still possible to have an allergic reaction. I take responsibility for my skin's response. If I suspect I have any communicable infection including sinus infection, cold symptoms, sore throat, I will inform Anastasia's Beautyland Vancouver Facial Rejuvenation Spa immediately to reschedule any appointments. Clients under the age of 18 require a parent/guardian to consent. I consent I do not consent Thank you! We honour your privacy and confidentiality at Anastasia’s Beautyland Vancouver Facial Rejuvenation Spa. © Anastasia’s Beautyland - Vancouver Facial Rejuvenation Spa, since 2024. All rights reserved.
