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Client Intake & Consent

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SPA SALDO Client Forms

Client Intake & Consent Form

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Personal Information

Full Name *

Email Address *

Date of Birth

Phone Number

Address

Emergency Contact

Health Information

Please check all that apply:

Pregnancy High Blood Pressure Diabetes Heart Conditions Epilepsy Skin Conditions (eczema, rosacea, acne, etc.) Allergies Recent Surgeries or Injuries Medications (especially for skin or pain) Any other medical concerns

Please list medications, allergies, or additional health notes:

Treatment History

Have you received any of the following in the past 6 months?

Chemical Peel Botox or Fillers Laser Treatments Microdermabrasion Retinol or Accutane use Skin Sensitivities

If yes, please explain skin sensitivities:

Client Acknowledgment

I certify that the information provided is complete and accurate to the best of my knowledge. I understand it is my responsibility to inform my provider of any changes to my health, medications, allergies, or treatment history before receiving services.

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savanah@spasaldo.com
+1 (505) 440-6190
501 14th St NW Albuquerque, NM 87104