SKIN CARE FORM *First Name *Last Name *Email *Mobile Phone ( ) – *Mobile Service Carrier AlltelAT&T WirelessBell MobilityBlueGrass CellularBoost MobileCarolina WestCellcomCellular SouthClaro Puerto RicoClear Talk WirelessComcel/ClaroConsumer CellularCricketDigicelElement MobileE-PlusFido CanadaH20 WirelessIllinois Valley CellularImmix WirelessKOODOOLimeLime (Jamaica)MessageMediaMetro PCSMovistarMovistar (Columbia)MTS – Manitoba TelecomNex-tech WirelessNextel (USA)NtelosO2O2 GermanyOpen Mobile (Puerto Rico)Optus Mobile (Australia)Orange France (FR)Orange UK (UK)PCS RogersPineCellRogers WirelessSasktel MobileSetar MobileSFRSMS CincinnatiSprint (Nextel)Sprint (PCS)Strata NetworksStrata/Ubet WirelessSunriseSwisscomTbaytelTelstra (Australia)Telus MobilityThreeTigo/Ola (Colombia)TIM ItaliaTIM USAT-MobileT-Mobile GermanyT-Mobile UKUff Movile (Columbia)Union – TelUS CellularVerizonViaeroVideotronVirgin Mobile – CanadaVirgina Mobile USAVodafone FranceVodafone GermanyVodafone ItalyVodafone SpainVodafone UK *Birthday Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 *Address Street 1 *Address Street 2 *Address City *Address State Any StateAKALARASAZCACOCTDCDEFLFMGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMPMSMTNCNDNENHNJNMNVNYOHOKORPAPRRISCSDTNTXUTVAVIVTWAWIWVWY *Address Postal Code *Gender Not SpecifiedMaleFemale *Referred By *Occupation *Anniversary Month123456789101112 Day12345678910111213141516171819202122232425262728293031 Year19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 *Emergency Contact Name *Emergency Contact Phone ( ) – *Emergency Contact Relationship *Have you had a professional facial treatment before? Yes No *Have you ever completed cosmetic surgery on your face or neck? No Yes *Do you have any metal implants or a pacemaker? Yes No *Do you have any of the following conditions: Please Note: To select more than one option, press and hold the Ctrl button (Windows) or the Command button (Mac) CancerDiabetesEpilepsyHeart ConditionHigh/Low Blood PressureHIVLupusSeizuresThyroid ProblemsNone of These *Are you currently under the care of a physician or dermatologist? Yes No *Are you pregnant or trying to become pregnant? Yes No *How many weeks pregnant are you? *Are you a smoker? Yes No *Do you take sinus medications? Yes No *Do you have allergic reactions to specific products, ingredients, foods, or oils? Yes No *Are you currently or have you in the past used any of the following: Please Note: To select more than one option, press and hold the Ctrl button (Windows) or the Command button (Mac) AccutaneAHABotox InjectionsCellex-CCortisoneDifferinIodineObajiRenovaRetin-ASiliconeSteriodsZyderm InjectionsNone of These *Which of the following products are you currently using for home skin care? Please Note: To select more than one option, press and hold the Ctrl button (Windows) or the Command button (Mac) Bar SoapCleansing LotionDay/Night CreamExfoliantEye CreamMaskSunscreenTonerNone of These *Are you currently using over the counter or professional brand home skin care products? Over the Counter Professional *If using professional skin care products at home, please tell us the brand? *Are you willing to change your diet and eating habits for healthier and more radiant skin? No Yes *Are you willing to change your routine and habits for healthier and more radiant skin? No Yes *How much water to you drink on a daily basis? * What are your current concerns about your skin? Please Note: To select more than one option, press and hold the Ctrl button (Windows) or the Command button (Mac) AcneAge SpotsBrown SpotsDrynessNone of TheseSensitivitySun DamageWrinkles *I hereby agree to adhere to all safety precautions and home skin care as recommend and that all information is accurate to the best of my knowledge. I understand the 24 hours notice of cancellation is required or I will be charged 50% of the service and 100% of the service for my second missed appointment. I Agree *By filling out this form electronically I hereby declare that all information is accurate and if it should change it is my responsibility to notify the therapist. I also hereby declare that Seventh Wonder Day Spa is not held liable for a customers failure to follow all after care procedures recommended for treatments. I Agree
