Facial Client Intake Form

1. What is todays date? *
2. How can we keep in touch with you? *
3. How did you hear about us? *
4. Please Select ALL health conditons you have. *
5. Please explain any selected above *
6. Please list any medical conditions not listed above *
7. Please list any medications (prescription and OTC that you are currently taking) *
8. Are you pregnant or lactating? *
9. Please list all product, food or seasonal allergies that you have: *
10. Do you smoke? *
11. Have you ever experienced Claustrophobia? *
12. What brand of skincare do you currently use?
13. What brand of make-up do you use?
14. Do you wear spf daily? *
15. Do you use any of the listed ingredients? *
16. Skin Conditions you would like to improve?
17. Have you ever had facial or body waxing?
Possible side effects from Facials, Waxing, Chemical Peels, Enzyme Peels, include but are not limited to the following: Mild to extreme redness, bruising, swelling, stinging, tenderness, dryness, flaking, scabbing, lightening or darkening of the skin, infections, bumpy appearances, or cold sores.
18. Most side effects are temporary and generally fade within 72 hours. (initial) *
19. I do not have any open skin lesions or active herpes outbreak at this time. (initial) *
20. I agree to adhere to all post care protocol. (initial) *
We truly appreciate your business and seek to provide you with the best experience possible. Please be advised of our new cancellation policy. We now require a credit card in order to confirm your reservation. If for any reason, you cancel within 24 hours or fail to show up to your appointment, we will charge your credit card 100% of your service cost. We thank you in advance for your understanding in this matter as we seek to insure that our service providers keep a full schedule at all times.
Please sign below confirming that all information listed above is correct and true, and that you agree to our cancellation policy. *