LUVEVA AESTHETICS SPA

Treatment Type

Qualifying Question

Patient Info

Schedule

Payment

Select Your Treatment

Skin & Face Treatments

Personalized facial treatments, skin rejuvenation, and anti-aging solutions

Body Treatments

Full-body therapies, massages, and specialized wellness treatments

Treatment Questionnaire

step 1 of 6

Please answer these questions honestly to help us recommend the best treatment for you.

What is your primary skin type? (Choose one)

Oily

Dry

Sensitive

Normal

What is your primary skin concern? (Choose one)

Dryness or dehydration

Fine lines or wrinkles

Uneven skin tone or hyperpigmentation

Acne or acne scars

General skin health and relaxation

Do you have any of the following skin conditions? (Check all that apply)

Active acne

Rosacea

Sunburn

Open skin lesions

Keratosis pilaris

Eczema

Dermatitis

None of the above

Q4. Are you currently taking or have you taken any of the following in the past 6 months?

Accutane (Isotretinoin)

Prescribed Retinoids

None of the above

Q5. What results are you looking for in your facial treatment?

Relaxation and stress relief

Smoother and brighter skin

Improved skin texture (e.g., acne scars, fine lines)

Exfoliation and hydration

Do you have any of the following active conditions? (Check all that apply)

Vascular lesions

Active herpes simplex (cold sores)

None

Treatment Questionnaire

step 1 of 7

Please answer these medical questions accurately to ensure your safety and the effectiveness of your treatment.

Q1. Are you Pregnant or Nursing?

Yes

Q2. Do you have any Thyroid Conditions?

Yes

Q3. Do you have the following?

Uncontrolled BP

Blood Clots

Heart Failure

Have a Pacemaker

Defibrillator implant

None of the above

Q4. Do you have Epilepsy?

Yes

Q5. Do you have multiple Sclerosis?

Yes

Q6. Do you have any recent Hospitalizations or Surgeries?

Yes

Q7. Do you have any metal implants in your body?

Yes

Patient Information

First name

Last name

DOB

Age

Phone

Password

Confirm Password

Address Information

Address (Street Number)

Address 2 (Apt. / Suite No) Optional

City

State

ZipCode

Schedule

Select Appointment

Click Agreed for the waiver

Payment

Card Number:

CVV:

Expiration Date: