Step
1
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2
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Email
(Required)
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Please select your service
(Required)
Massage
Facial
Occupation
Who should we thank for referring you today?
Existing clients who refer 4 new clients to Spa One Nineteen, receive 1 FREE massage of equal or lessor value. Ask your service provider how to benefit from this referral program.
How did you hear about us?
(Required)
Facebook
Twitter
E-Blast
New Member
In facility for another reason
Radio
Website
Word of Mouth
Associate
Other
Other
Are you currently under a physicians care?
(Required)
Yes
No
If yes, please explain
(Required)
Please check the following that are applicable
Blood Clots or suspicion of Blood Clots
Cancer
Allergies
Aids/HIV
Asthma
Tuberculosis
Diabetes
Epilepsy
Heart Attack
Hepatitis
Immune Compromised
Kidney Disease
Shingles
Metal Implants
Neurological Disease
Nail Fungus
Blood Circulation
Keloid Scarring
Decreased Range of Motion
Neck Pain
Whiplash
Headaches
Disk Problems
Surgery
High/Low Blood Pressure
Herpes/Cold Sores
Sinus Problems
Mid Back Pain
Sprains
Low Back Pain
Seizures
Serious Injury
Abdominal Pain
Nervous Tension
Arthritis, Bursitis
Joint Pain
Varicose Veins
Broken Bones
Hormone Imbalance
Pregnant: By checking this, I am verifying I am at least 12 weeks along
List all medications, vitamins, and drugs you are taking and reason
What is the reason for your visit today?
Any specific skin challenges
(Required)
Flaking
Tightness
Sunburn
Eczema
None
Other
Other
(Required)
Have you ever had a reaction to any treatments?
(Required)
By digitally signing this intake form, I agree to the UAB St. Vincent's One Nineteen Spa cancelation policy. I recognize that if I cancel within 24 hours of my service, it will be marked as a missed appointment. I am allowed 3 missed services per calendar year.
(Required)
Tell us a little about your skin
Does your occupation require you to work outdoors?
(Required)
Yes
No
Which of the following best describes your skin type
(Required)
(Skin type I) Creamy Complexion - Always burns easy, never tans
(Skin type II) Light Complexion - Always burns, tans minimally
(Skin type III) Light/Matte Complexion - Burns moderately, tans gradually
(Skin type IV) Moderate Complexion - Seldom burns, always tans well
(Skin type V) Deep Complexion - Rarely burns, tans easily
(Skin type VI) Dark Complexion - Never burns, deeply pigmented
Have you received a facial treatment before?
(Required)
Yes
No
If you could change one thing about your skin, what would it be?
(Required)
Do you have any special skin challenges or concerns pertaining to your face or body? If yes, please note
Have you ever had chemical peels, laser or microdermabrasion?
(Required)
Yes
No
If yes, has it been within the last month?
Yes
No
Do you use Retin-A, Renova, Retino, Tretnoin or any Vitamin A derivative products? If yes, please note
(Required)
If no, have you used any in the past 3 months?
Yes
No
Have you used acne medication? If yes, when and what drug treatment?
(Required)
Have you used any of the following hair removal methods in the past six weeks? Check all that apply.
Dermaplane
Electrolysis
Shaving
Laser
Plucking
Tweezing
Waxing
Which of the following products do you use on a regular basis?
(Required)
Cleanser
Toner
Day Moisturizer
Eye Product
Night Moisturizer
Mask
Scrub
Body lotion
Sunscreen
Foundation
By digitally signing this intake form, I agree to the St. Vincent's One Nineteen Spa cancelation policy. I recognize that if I cancel within 24 hours of my service, it will be marked as a missed appointment. I am allowed 3 missed services per calendar year.
(Required)