Client Form | The Green House Spa

First name

Last name

Birthday

Month

Day

Year

Type of Skin

Normal

Dry

Oily

Combination

Any Allergies?

Are you pregnant?

Yes

No

Are you presently using (or used in the past) Azlex, Differin, acne medication, Retinols, Tazarac, Glycolic or Alpha Hydroxy Acids? If yes, please list down below. If not, then please put no.

Are you presently taking any blood thinners?

Yes

No

Please check if you are affected by or have any of the following:

Please explain above problems or list any other significant issues.

I understand that the services offered are not a substitute for medical care, and any information provided by the therapist is for educational purposes only and not a diagnostic.

I understand that the information is to aid the therapist in giving better service and is completely confidential.

Type your name down below acknowledging what you read.