Client Intake Form

“Please take a few moments to complete our Client Intake Form. Your responses help us tailor each treatment to your unique needs, ensuring the safest and most luxurious spa experience possible. All information is kept strictly confidential.”

First Name

Last Name

Birthday

Month

Day

Year

Have you ever had a facial before?

If yes, when was you last facial?

Do you have any skin concerns pertaining to your face or body?

If yes, please specify.

Have you used any Retin-A, Renova, AHA, or Retinol derivative products in the past 90 days?

Yes

No

How often do you use Retin-A, Renova, AHA, or Retinol derivative products?

Last time of use?

Have you ever had chemical peels, laser or microdermabrasion?

Yes

No

If yes, please specify when you had your last treatment and how often.

Are you taking oral contraceptive or undergoing any hormone replacement therapy?

Yes

No

If yes, please specify when you had your last treatment and how often.

Have you ever used an acne medicine?

Yes

No

If yes, please specify name of the acne medication and how often it is taken?

Do you have any known allergies?

Yes

No

Please list allergies below.

Have you had Botox, Restylane or Collagen injections?

Yes

No

If yes, please specify how often and when was your last treatment?

Are you taking oral contraceptive or undergoing any hormone replacement therapy?

Yes

No

If yes, please specify.

Are you pregnant or breast-feeding?

Yes

No

Is there anything else you would like to share with your expert?

I understand that my decision to undergo facial/body treatment is entirely voluntary. I confirm that I am choosing to receive this service without pressure or coercion of any kind. I acknowledge that no guarantees or promises have been made regarding specific outcomes or results from this treatment.

I agree to provide full and accurate information regarding my medical history, allergies, current medications (including topical or oral), and skincare routine. I understand that this information is essential for the esthetician to provide a safe and effective treatment. I accept full responsibility for any consequences that may occur due to withholding or misrepresenting this information.

I acknowledge that facial treatments involve certain risks, including but not limited to redness, irritation, breakouts, allergic reactions, and in rare cases, scarring or burns. I understand that outcomes may vary depending on my skin type, health conditions, and lifestyle. I agree to communicate any discomfort during or after treatment, and I accept that results are not guaranteed.

By signing this form, I agree to release and hold harmless the esthetician and Lumé Spa, including all employees and affiliates, from any and all liability for injury, loss, or damages that may result from the service-except in cases of gross negligence or willful misconduct.

I acknowledge that I have received, or will be provided with, detailed pre- and post-treatment instructions. I agree to follow all care recommendations given by the esthetician and understand that failure to do so may impact my results or increase the risk of complications.

I understand that Lumé Spa requires a minimum of 24 hours' notice for cancellations or rescheduling. A 10-minute grace period is allowed for all appointments. I agree that failure to provide sufficient notice, or missing an appointment without notice, may result in a fee of 50% of the total cost of the booked services, which will be charged to the card on file.

If the appointment is rescheduled, the cancellation fee will be automatically applied toward the cost of the new service. Repeated no-shows may lead to loss of deposit or refusal of future bookings.

This agreement shall be governed by the laws of the State of Florida. If any part of this agreement is found to be invalid or unenforceable, the remaining provisions shall remain in full effect.

Photo/Video Release

I give permission for Lumé Spa to take and use before-and-after photos or videos for educational, promotional, or marketing purposes. I understand that my identity will be protected unless I provide written consent otherwise.

I do not give permission for the use of photos or videos of my treatment.

Signature

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Client Intake Form

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