Ask us about our referral program!

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Refresh Med Spa

1001 Calumet Avenue Dyer, IN 46311

Inside Northwest Cancer Center

Hours Of Operation

Mon-Fri 9:00 AM - 5:00 PM

Every other Sat 8:00am – 3:00pm

Refresh Med Spa

Ask us about our referral program!

1001 Calumet Avenue Dyer, IN 46311

Inside Northwest Cancer Center

Hours Of Operation

Mon-Fri 9:00 AM - 5:00 PM

Every other Sat 8:00am – 3:00pm

Call Us Today!

Home
About Us
Meet Our Staff
Services
Products
- iS Clinical
- Face Reality
Before & After Photos
Client Forms
Monthly Specials
Gift Certificates
Contact Us

New Client Intake Form

*Name

*Date of Birth

*Address

*Telephone

*Email

Okay to e-mail?

Yes

No

*Emergency Contact

*Telephone

*Your Skin Goals and Concerns

Your Skin Type

Normal/Combo

Oily

Sensitive

Dry

Mild Acne

Moderate Acne

Mature & Aging

What skin products are you currently using?

What makeup products are you currently using?

Does your job and lifestyle require that you work/play outdoors?

Do you wax your facial skin on a regular basis?

Yes

No

If yes, when was the last time?

Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?

Yes

No

If yes, was it within the last month?

Yes

No

Are you using Retin-A?

Yes

No

Are you using Benzoyl Peroxide?

Yes

No

Do you have any allergies or sensitivities?

Have you ever experienced a reaction to any of the following?

cosmetics

medicine

iodine (shellfish)

latex

pollen

food/fruit

animals

fragrance

alpha hydroxy acids

sunscreens

Free Text

Do you have any of the below health issues?

Cancer?

Yes

No

Chemotherapy?

Yes

No

Circulatory issues?

Yes

No

High blood pressure?

Yes

No

Arthritis?

Yes

No

Hysterectomy?

Yes

No

Hormonal imbalances?

Yes

No

Thyroid?

Yes

No

Diabetes?

Yes

No

Pregnant?

Yes

No

Lactating?

Yes

No

Planning to be pregnant?

Yes

No

Psoriasis?

Yes

No

Recent surgeries?

Yes

No

Cold Sores?

Yes

No

Eczema?

Yes

No

Do you take any medications?

Accutane?

Yes

No

Antibiotics?

Yes

No

Birth Control?

Yes

No

I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.

I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.

Date

Thank you for contacting us.
We will get back to you as soon as possible.

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Phone: 219-515-6613 | Email: info@refreshmedspanwi.com | Address: 1001 Calumet Avenue, Dyer, IN, 46311

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