Formerly...Saisir Le Jour Day Spa - Saisir le jour, carpi dium...let us help you 'seize the day'...
All Gift Certificates are redeemable with Tara Smith, Licensed Esthetician and Manicurist
No longer offer MASSAGE



Facial Consent Form

Please click on link and read. Then choose Advances Therapies Option below for consent.

Please fill out ALL personel info as some people have the same name.

We want to be sure the health info is connected to the correct profile.

Health history for Facial services
Name
Phone
Address
Email address
Birth Date
Skin Type
Are you currently under a physician's care?
Yes
No
List any surgeries you had within the last 9 months
Medications, Vitamins, and or special concerns pertaining to your skin?
What skin care products are you currently using?
Soap
Cleanser
Toner
Mask
Moisturizer
Scrub/Peel
Do you experience breakthrough oily shine during the day?
Yes
No
Do you experience skin breakouts?
Yes
No
Have you or do you?
Smoke
Use Retin-A
Exercise Regularly
Wear Contact Lenses
Use the acne drug Accutane in the past 6 months
Do you have any metal implants in your body?
Yes
No
How much water do you consume daily? (ex. ounces)
Do you ever experience these conditions?
Flakiness
Tightness
Obvious Dryness
Do you use sunscreen, sun block, SPF?
Yes
No
Do you burn easily in moderate sunlight?
Yes
No
Do you blush easily when nervous?
Yes
No
Do you have a tendency to redness?
Yes
No
Have you suffered sinus problems?
Yes
No
DO YOU HAVE ROSACEA?
Yes
No
Are you Claustrophobic?
Yes
No
What massage pressure do you prefer?
Have you had recent dental X-Rays?
Yes
No
I give consent for facial services.
Yes
No
I give consent for Advanced Therapies and Enzyme Facials
Yes
No