978-650-2895 | 978-244-0300

3 Littleton Rd Unit 1 | Westford, MA 01886
Westford/Chelmsford Line
(Formerly Of Chelmsford)

Please check Appointment Guidelines link before coming to your appointment it will help you understand the new procedures we need to follow.

A Spa To Remember Skin Care Consent Form

    Personal Information

    First and Last Name*
    Phone Number*
    Email Address*
    Date of birth*
    Zip Code*
    Do you wish to receive special weekly discounts via SMS (text messaging)? *
    How did you hear about us?*
    Are you on Instagram? Follow us! @aspatorememberwestford

    A Spa To Remember Skin Care Consent Form

    Are you pregnant? *
    Do you wear contact lenses? (Please remove contacts if eyes are sensitive or if having microdermabrasion treatment)*
    Do you currently have sunburn/windburn/red face?*
    Are you in the habit of going to tanning booths?*
    Do you currently get facial waxing/electrolysis?*
    Are you currently using Retin-A/Renova/Differin?*
    If so please answer the following questions: What Strength? For how long? How frequently?
    Where is it applied?
    Are you currently using Acutane?*
    Are you having a microdermabrasion treatment?*
    Do you have regular collagen injections?*
    Do you have regular botox injections?*
    What type of work do you do?*
    Airline travel? If so how often?*
    Do you participate in vigorous aerobic activity or sports?*
    Have you ever had a peel?*
    If so was it within that past 14 days?*
    What kind? Please describe your reaction.*
    Have you recently had a facial surgery?*
    Have you recently had any laser treatments?*
    Do you smoke?*
    Develop cold sores/fever blisters?*
    Are you affected by, or have any of the following:
    Check all that apply.
    Are you allergic/sensitive to?
    Check all that apply.
    Any other allergies?*
    Are you sensitive to alcohol based products? *
    Are you taking any medication at this time? (antibiotics increase sensitivity) *
    Are you using glycolic/AHA home care products? *
    If so which one(s)?
    Have you ever used any products that caused a bad reaction? *
    What is your daily home care regimen? *
    What are the cosmetic improvements you would like to see in your skin? *

    Payment Information

    We require a 24-hour cancellation notice or appointment rescheduling of all services.
    A Charge of 50% of the service will be incurred for all missed appointments.

    Please note that this card will only be charged in the case of a same-day cancellation or a no-show appointment, please bring in a separate payment method at the time of your service.

    Type of card*
    Name on Card*
    Card Number*
    Expiration Date*
    CVC Number*
    Please input your name, the date and signature below.