808-344-4081
Maui Lani: 169 Ma'a Street
​Kahului, HI 96732
Aloha
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Please answer the following questions to the best of your knowledge. This information will help your Licensed Esthetician provide a custom experience based on what will be most effective and safe for you!
Client Consultation Questionnaire
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Name
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First
Last
Date of Birth (MM/DD/YYYY)
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Address
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Line 1
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City
State
Zip Code
Country
Phone Number
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What is the best email address to use for you?
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Emergency Contact
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First
Last
Emergency Contact Phone Number
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Referred by
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First
Last
What is the reason for your visit?
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How may we contact you? Please check all that apply.
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Email
Text Message
Phone Call
Are you under a Physician's care? If yes, please explain below.
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No
Yes
If Yes is checked above, please describe here.
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Are you allergic to tree nuts?
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No
Yes
Please list any allergies here.
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Do you wear contact lenses?
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No
Yes
Are you pregnant or trying to become pregnant?
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No
Yes
Do you have skin sensitivities? If yes, please describe below.
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No
Yes
If Yes is checked above, please describe here.
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Have you had skin cancer?
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No
Yes
Do you have any metal in your body? If yes, please describe below.
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No
Yes
If Yes is checked above, please describe here.
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Please list all medications, both oral and topical.
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Are you currently using, or have you ever used, prescription acne or anti-aging medications or creams? If yes, please describe below.
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No
Yes
If Yes is checked about, please list what medication(s) and how long you have used them.
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Are you affected by any of the following? Check all that apply.
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Asthma
Epilepsy
Herpes
Lupus
Sinus
Diabetes
Cardiac Problems
Headaches
Hysterectomy
Fibromyalgia
Urinary
Immune Disorder
Eczema
Hepatitis
High Blood Pressure
Pacemaker
Skin Disorders
Other, please describe below.
What problems are you currently experiencing with your skin?
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Which home products would you like more information on? Please check all that apply.
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Cleanser
Toner
Serums
Eye Cream
Moisturizer
What is your current home routine, AM & PM?
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Please read the statements below and check the box preceding each statement to acknowledge.
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I understand the information here is to aid the skin care therapist and it is not a substitute for medical care. I understand the questions and have answered them honestly and correctly.
I understand that the services including facials, waxing and tinting given at Maui Skin & Body Studio, are for the sole purpose of skin cleansing, body and mind relaxation and rejuvenation.
I understand that it is imperative to tell my Esthetician about any oral or topical medications prior to any facial, waxing or other treatment services.
I understand that Maui Skin & Body Studio, and staff do not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility of the use of The Spa 10 at my own risk, and do not hold The Spa 10 or staff liable for loss, damage or injury.
I understand that results are personal and not guaranteed.
I certify that the information supplied here is correct and that I have not withheld any information that may be relevant to my treatment at Maui Skin & Body Studio.
Please note any additional information that may be of importance to your Licensed Esthetician regarding the spa treatment you may be receiving.
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Signature (your name submitted below will be considered as your electronic signature)
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Date Signed (MM/DD/YYYY)
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