Home
About
About Us
Testimonials
NeuroSpa Experience
Treatments
Massage Therapy
Therapeutic Massages
Pregnancy Massages
Spa & Healing Massages
Facials & Peels
HydraFacials
Image Facials
Peels
Microneedling
Dermaplaning
Spa Treatments
Eyelash Extensions
Brow & Eyelash Tinting
Manicures & Pedicures
Waxing
Men’s Spa Services
Body Treatments
Medical Laser
Laser Hair Removal
Laser Facial Rejuvenation
Skin Contouring & Resurfacing
Wellness
Weight Loss
Imagine Laserworks
Membership
Blog
Spa Packages
Promotions
Holiday Spa Packages
Wedding Ready Packages
Contact
Massage Intake
Gift Cards
Shop Online
Search
Menu
Menu
Image Skin Health Form
Name
*
First
Last
Home Phone
*
Work Phone
Cell Phone
Email
*
Enter Email
Confirm Email
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Occupation
*
Referred By
Date of Birth
*
MM slash DD slash YYYY
Age
*
Family Physician
*
Do you smoke?
*
Yes
No
How often?
*
Select
Less than once per day
Once or twice per day
Three or four times per day
Five or more times per day
Are you living with a smoker?
*
Yes
No
Have you been treated for:
Acne
Depression
Skin disease
High blood pressure
Cold sores
Diabetes
Cancer
List of allergies
List of medications that you are currently taking
Are you:
Pregnant?
Trying to get pregnant?
On hormone therapy?
Are you prone to cold sores?
*
Yes
No
Your current level of stress
Select
1
2
3
4
5
6
7
8
9
10
1 = Not stressed, 10 = Very stressed
Your normal level of stress
Select
1
2
3
4
5
6
7
8
9
10
1 = Not stressed, 10 = Very stressed
Do you take supplements/vitamins?
*
Yes
No
How many ounces of water do you drink daily?
*
Select
Less than 2
2 - 4
5 - 7
8 - 10
More than 10
Do you exercise?
*
Yes
No
How often?
*
Select
Less than once per day
Once or twice per day
Three or four times per day
Five or more times per day
Your last sunburn
*
MM slash DD slash YYYY
Do you use tanning beds?
*
Yes
No
Have you ever been under the treatment plan of a:
Dermatologist
Plastic Surgeon
Aesthetician
When you go out into the sun, do you:
*
Select
Always burn
Usually burn
Sometimes burn
Rarely burn
Very rarely burn
Never burn
Would you be interested in cosmetic surgery?
*
Yes
No
What procedure?
*
Are you concerned about:
Sun Spots
Skin Laxity
Dry/Rough Skin
What skin care line are you currently using?
Do you use a daily environmental protection product (sunscreen)?
*
Yes
No
Why not?
How do you feel about the overall quality of your skin?
*
Select
1
2
3
4
5
6
7
8
9
10
1 = Bad, 10 = Fantastic
Your skin type is:
*
Select
Normal
Dry/Dehydrated
Oily
Acne Prone
Rosacea
Δ
Scroll to top
