Client Intake Form | The Herrington Inn & Spa

First Name *

Last Name *

Telephone *

E-mail *

Date of Birth *

Would you like to hear about promotions and specials?

Yes

List any known allergies or Special needs *

Are you pregnant? *

Yes

If yes, list trimester

Are you breastfeeding?

Yes

Active treatment or history of cancer *

Yes

If Yes please list

Recent Surgeries (within the past 3 years) *

Yes

If Yes please list

Skin Care Treatment

Are you currently prescribed medicine to care for your skin?

Yes

If yes, Please list

Do you currently apply Retinol products or Retin A to your skin?

Yes

Are you wearing contact lenses?

Yes

Do you apply any Glycolic products or any other exfoliating acids regularly at home?

Yes

Area's of Concern

Fine lines/Wrinkles

Acne/Clogged Pours

Dryness/Dehydration

Eyes Puffy/Fine Lines

Excessive Oil Production

Excess Pigment/Scaring

Redness/Sensitivity

Back Acne/Ingrown Hairs

Check if any currently apply to you

Sunburn

Rosacea

Recent Face Wax

Accutane (within 12 months)

Eczema/Dermatitis

Medical Chemical Peel (within 2 weeks)

Metal Implants

Open Wound (face or neck)

Infection or HSV-1/HSV-2 Face or Neck

Please read and sign where indicated

In consideration of my participation in Spa services (massage, waxing, , facials, body treatments, etc.) at The Spa at The Herrington, I hereby release, discharge and covenant not to sue The Spa at The Herrington, including their respective directors, officers, employees, agents, representatives, insurers, clients, successors, assigns, and any property owners, (“Released Parties”) and further release from liability the Releases Parties from and all claims, losses, damages, or liability, INCLUDING NEGLIGENCE, AND LOSSES DUE TO THE NEGLIGENCE OR RELEASED PARTIES WHEN PERFORMING OR INSTRUCTING ANY SPA SERVICES OR MAINTAINING THE FACILITY, (“Losses”) resulting in personal injury, accidents or illnesses (including death), and property loss, including theft, arising from, participation, in the Spa Services or using the Facility releases Parties are not able to diagnose illnesses or prescribe medical treatments or pharmaceuticals. Spa Services are not medical, and should not be considered, a substitute or diagnosis or treatment by a licensed medical professional. Guests should consult a physician requiring participation in the Spa Services and shall update Released Parties with any changes in health and Released Parties shall not be liable for failure to do so.

Personal Property

Please do not bring or leave valuables in the Facility Released Parties are not liable for any theft or loss of personal property, including jewelry or other personal items. I understand participation in the Spa Services carries certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries; my participation in the Spa Services is voluntary.

I HAVE READ AND UNDERSTAND THIS WAIVER, AND I RELEASE THE SPA AT THE HERRINGTON, AND ALL PARTIES FROM ANY AND ALL LIABILITY.I ACKNOWLEDGE THAT I AM SIGNING THIS WAIVER VOLUNTARILY.

Printed Name

Signature

Date

Appointment Date

Spa Intake Form for Skin Care