The Vine Luxury Spa Client Consultation Form
Please fill out this form before your appointment to ensure the utmost experience when arriving at The Vine Luxury Spa.
* denotes a mandatory field.
First Name
(*)
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Last Name
(*)
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Date of Birth
(*)
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Address
(*)
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City
(*)
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Province
(*)
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
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Postal Code
(*)
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Telephone
(*)
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Cell
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Email
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Doctors Name
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Emergency Contact
(*)
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Emergency Contact Phone
(*)
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Occupation
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How Did you Hear About Us?
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What is your primary concern or what bothers you the most and is the reason for your consult today?
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Please list other areas of concern or procedures that you would like to discuss with our staff
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SKIN HISTORY
Skin Quality
(*)
Dry Skin
Normal Skin
Oily Skin
Oily T Panel
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Skin Sensitivity
(*)
Normal - not sensitive
Sensitive
Very Sensitive
Reactive
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Skin Breakouts
(*)
Acne
Acne Rosacea
Occasional Pimples
Breakout from Menstrual Periods
None
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In order to better establish your skin type, please tell us your ethnic heritage
(*)
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Please check which best describes your reaction to sun exposure:
Skin Type I - Never tans, always burns (extremely fair skin, blonde hair, blue/green eyes)
Skin Type II - Occasionally tans, usually burns (fair skin, sandy/brown hair, brown eyes)
Skin Type III - Often tans, sometimes burns (medium skin, brown hair, brown eyes)
Skin Type IV - Always tans, never burns (olive skin, brown/black hair, dark brown/black eyes)
Skin Type V - Never Burns (dark brown skin, black hair, black eyes)
Skin Type VI - Never burns (black skin, black hair, black eyes)
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Do you use a sunscreen daily?
Yes
No
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Do you or have you done any of the following?
Sunbathing
Outdoor Sports
Use Sunbeds
Gardening
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Are you, or have you been treated for acne with any of the following?
Topical vitamin A (eg Retin A)
Vitamin A varients (eg Diferin Gel)
Benzoyl Peroxide
Azelaic Acid
Salicylic Acid
Alpha Hydroxy Acids
Oral Antibiotics
Isotretinoin (eg Roaccutane)
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Other (please specify)
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Are you, and have you been treated with any of the following:
Topical Corticosteroids
Oral Corticosteroids
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Other (please specify)
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State affected areas:
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Are you, or have you been treated with any of the following:
Vitamin A products
Vitamin D products
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Other (please specify)
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State affected areas:
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Have you ever had any of the following:
Facial surgical procedures
Laser treatments
Laser hair removal
Dermabrasions
Moles or sun spots removed
Waxing
Chemical peelings
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Other skin care treatments (please specify)
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Are you taking any of the following?
HRT (Hormone Replacement Therapy)
Contraceptive Pill
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Medication (please specify)
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Vitamin Supplements (please specify)
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Are you, or do you have any of the following:
Allergies
Claustrophobia
Porphyria
Heart Condition
Rheumatism
Pregnant
High or Low Blood Pressure
Hypothyroidism
Hyperthyroidism
Facial/Metal Implant
Constipation
Diabetes
Cancer
HIV (Aids)
Back Problems
Untreated Sinusitis
Arthritis
Asthma
Cold Sores
Keltoid or Thick Scars
Epilepsy
Psoriasis
Eczema
Pacemaker/Cardiac Irregularities
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What Skin Care Products are you currently using?
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Please enter the letters you see:
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© The Vine Luxury Spa | #202 9814 - 97 Street Grande Prairie, Alberta T8V 8H5 | P. 780.814.7558
