Facial Form

Full name*

Age*

Are you pregnant?*

Yes
No

Please indicate how many weeks along you are*

How would you describe your skin?*

What is the texture of your skin?*

Choose all that apply

Soft
Rough
Oily

Where is your skin soft?*

Where is your skin rough?*

Where is your skin oily?*

Do you see small white dandruff on the surface of your skin?*

Yes
No

Where do you see this?*

How does your skin react to outside aggression?*

e.g., wind, cold, heat, etc

Skin blushes easily and is irritated
No affect
Skin goes red

Is the redness permanent?*

Does your skin have any broken capillaries (red veins)?*

How does your skin react to sun?*

It always burns
It turns red and then tans
It tans easily

Does your skin have hyperpigmentation?*

e.g., multiple brown spots

Where are your brown spots located?*

Oil production*

Skin feels tight during the day, as though I need to re-apply cream
Wake up in the morning shiny
Develop shine on my skin by mid day
I don't really notice

Where do you notice the shine?*

Where do you notice the tightness?*

Do you get pimples/breakouts?*

Do you go to the tanning salon?*

How often do you go?*

What are your skin concerns?*

Topical products you are currently using*

Retin A
Renova
Differin
Glycolic Acid 5% or more
Accutane
Anitbiotics
High Concentration AHA
N/A

At-Home Care Routine

Makeup Removal and Skin Cleansing*

Choose all that apply. You can select multiple items by holding CTRL on Windows & clicking on choices or if you're on a MAC you can hold CMD & click on multiple options

Do you use a toner?*

Yes
No

Do you moisturize?*

Yes
No

When do you moisturize?*

Morning & Evening
Morning only
Evening only

Do you exfoliate?*

Yes
No

When do you exfoliate?*

Once a week
2-3 times a week
Almost every day

What type of exfoliant do you use?*

Scrub with beads
Gentle scrub with no beads
Enzyme mask
Gommage

Do you use serums?*

Yes
No

What types of serum(s) are you currently using?*

When do you use your serum(s)?*

Morning & Evening
Morning only
Evening only

Do you wear SPF?*

Yes
No

How often?*

Everyday
Only when I'm outside
Only when I remember to

Do you re-apply during the day?*

Yes
No

What type is it?*

It's in my moisturizer
It's in my makeup
Separate SPF 30
Separate SPF 50
I'm not sure

Any known allergies?*

Yes
No

Please list any allergies you have

Are you taking any medications right now?*

Yes
No

Please list any medications you are taking*

Are there any concerns which you would like your service provider to focus on or pay particular attention to

Please Read Carefully

I acknowledge and understand that a person can unintentionally spread COVID‐19 to others even if they do not feel sick or have symptoms.

I acknowledge and understand that if I have travelled outside of Canada that my spa service will have to be rescheduled to a later date.

I acknowledge and understand that my service provider, the staff, this business, or the owner of this business cannot completely control the spread of COVID‐19 and I have chosen to enter this business and consent to receive close contact service(s) with full knowledge of the risk of contracting COVID‐19 when social distancing is not observed.

I acknowledge and understand that I should not attend my spa appointment if I am experiencing any symptoms of COVID-19.

Because we are all in this together, all employees of Melt Mineral Spa also acknowledge and agree to these same standards and statements every day. By ticking the box below, I agree not to hold my service provider, the staff, this business, or the owner of this business liable for any exposure to COVID‐19 while at Melt Mineral Spa.

I acknowledge and agree to the following:*

Yes

I acknowledge and understand that the use of cell phones in Melt Mineral Spa is prohibited.

I acknowledge and understand that there are risks associated with services provided by Melt Mineral Spa. I acknowledge that my participation in these treatments is entirely voluntary.

I agree to discuss my concerns about possible risks with my service provider before the treatment and immediately advise them if I become uncomfortable in any way during my treatment.

I acknowledge and understand that it is important for the service provider to know my relevant medical history and that I have disclosed all known medical conditions, including any mental or emotional conditions for which I have received treatment within the last 12 months.

I will disclose any new condition that may develop after my completion of this form. The information disclosed by me is true and complete to the best of my knowledge.

I authorize copies of any patient record created at Melt Mineral Spa to be shared with all registered professionals who work at Melt Mineral Spa who may provide me with treatment.

I acknowledge inappropriate conduct of any nature will not be tolerated and may result in the treatment being terminated.

I assume all risks involved in my participation in the services provided by Melt Mineral Spa, its employees and spa service providers. I agree to release and forever discharge Melt Mineral Spa, its owners, its directors, employees and contractors from any claims, losses, damages, actions or causes of action arising out of any loss, injury, damage to my person or property arising from my involvement with the services provided by Melt Mineral Spa.

The contents of this form and my patient records will be kept confidential unless I have expressly or impliedly consented to the release of my information.

I acknowledge and confirm that no guarantee or assurance of treatment results have been made to me regarding my services provided by Melt Mineral Spa.

I acknowledge that I am over the age of 18, have read this Waiver, understand it and I agree to be bound by this Release and Indemnity.

*if I do not understand and therefore am not capable of providing consent, or under the age of 18, this consent is instead provided by an individual who is authorized and able to make health care decisions on my behalf (parent or legal guardian).

I acknowledge and agree to the following:*

Yes

Date signed*

Signature*

First Last

Name

This field is for validation purposes and should be left unchanged.

At-Home Care Routine

Please Read Carefully

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