New-Client — Vanilla Sugar Day Spa Services l Peoria Illinois

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Home About About Us Our Team Spa Specials Policies & Etiquette Client Rewards Active Military & Veterans Podcast Filter Free & Flawless Book Blog Contact Careers Facial Treatments New Facial Clients MoveoGlo Laser Facials Signature Facials Microneedling Microdermabrasion HydroDiamond Facial Microcurrent Chemical Peels Dermaplaning Bio RePeel Working with Elizabeth Acne How Our Acne Program Works Acne Reducing Treatments Virtual Acne Coaching Chest & Back Treatments Acne Scars Treatments 8 Week Case Study Pore Clogging Ingredients Benzoyl Peroxide Use in Acne Acne Podcast Episodes KOREAN SKIN CARE Korean Skin Treatments Hair Removal Laser Hair Reduction Female Brazilian Female Waxing Male Waxing Manscaping Laser FAQ's Before & After Waxing Waxing FAQ's Spray Tanning Bridal Tanning Male Spray Tanning Female Spray Tanning Spray Tanning FAQ Before and After Spray Tanning spray tanning pricing Age Requirements Lashes & Brows Volume Eyelash Extensions Modern Lash Looks Eyelash Extension Care Brow Treatments Lash Lifts Lashes FAQ's Injectables Botox Botox Pro Tips Lip Flips Shop

Peoria, IL

(309) 219-1140 Book Now

Please input the hardcopy information from the Facial & Waxing Intake Form:

1. Demographics Information

Intake Date *

First Name *
Last Name *
Gender

Date of Birth

Street Address
City
Zip/Postal Code

Cell Phone

Email *

Would you like to be on our Email Newsletter and receive special?

Yes No

2. Skin Care Treatment Background

Have you ever had a facial before?

Yes No

Have you ever had waxing before?

Yes No

If yes, where?

Soderstrom, Five Senses, other major competitor Out of the area

If yes, how long ago?

Exposure to the sun

Never Light Moderate Exessive

Have You Used Accutane in the last 12 months?

Yes No

Have You Used Retin-A in the last month?

Yes No

Other Oral or Topical Skin Medications in the last 6 months?

Yes No

Other oral/topical skin medications in the past 6 months?

Yes No

If yes to other oral/topical medications, please describe

Are you using any of the following?

AHA's Salicylic Acid Retinol

Have you had chemical peels, microdermabrasion or resurfacing?

Yes No

What brand of prodcuts do you use?

cetaphil

Soderstrom brand

Rodan & Fields

Other

What cleanser skin product do you use?

Toner product do you use?

Moisturizer product do you use?

Serum product do you use?

Masque product do you use?

Exfoliator product do you use?

My treatment goals are:

Anything else we should be aware of before starting?

3. Medical/Health Background Information

Are you pregnant?

Yes No

If yes, how far along is your pregnancy?

Exposure to Sun?

Never Light Moderate Excessive

Food allergies?

Yes No

Allergies to latex?

Yes No

Other allergies?

Yes No

Allergy Notes

Are you currently on any medications?

Yes No

If Yes, please list any medications:

Do you have (select all that apply):

Office Hours

Mon - Thu: 9 am - 8 pm

Friday: 9 am -6 pm

Saturday: 9 am - 3 pm

Sunday: Closed

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