Facial Intake Form
  • Date:*
     / /
  • Date of Birth:*
     / /
  • Do you wear contact lenses?*

  • Skincare

  • Have you ever had a facial treatment before?

  • Have you ever had a body spa treatment before?

  • Do you have any special skin problems or concerns pertaining to your face or body?*

  • Have you ever had chemical peels, laser, microdermabrasion, mircoblading, or dermaplaning?*
  • Have you had these services in the last month?*
  • Have you used Accutane in the past year?*
  • Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or  Retinol/vitamin A derivative products?*

  • Have you used any of the products above in the last 3 months?*
  • Have you used an acne medication?*
  • Do you form thick or raised scars from cuts or burns? No Yes*
  • Do you have Hyperpigmentation(darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

  • Are you using any topical creams, lotions, or oral antibiotics for acne, skincancer, anti-aging or hyperpigmentation?*

  • Have you recently used any self-tanning lotions, creams or treatments?

  • Have you used any of the following hair removal methods in the past six weeks?

  • What areas of concern do you have regarding your Skin: (Please check any that apply and explain)

  • Eyes:

  • Lips

  • Health History

  • Have you been under the care of a physician, dermatologist, Oncologist, or other medical professional within the past year?*

  • Any recent surgery, including plastic surgery?:*

  • Any kind of tumor or cancer?*

  • Have you had any piercings, tattoos, or permanent cosmetics?

  • Has your physician discussed concerns about raising your body temperature?*
  • Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)*
  • Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)*
  • Have you had any of these health conditions in the past or present? (Please check all that apply and provide additional information in the space provided)*
  • Do you smoke?*
  • Do you follow a restricted diet:*
  • Do you follow a regular exercise program?:*
  • What is your stress level?*

  • List your daily consumption of:

  • Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
  • How frequently are you exposed to the sun or a tanning bed?*
  • Does your job require that you work outdoors?*
  • Do you have any metal implants or wear a pacemaker?*
  • Have you ever experienced claustrophobia?*
  • Do you suffer from sinus problems?*

  • Women:

  • Are you taking oral contraceptives?

  • Any recent changes to or from your contraceptive treatment?

  • Are you pregnant or trying to become pregnant?
  • Any menopause problems?

  • Consent

  • I hereby consent to and authorize Kia Bradshaw to perform a facial treatment. 

    I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved, by Kia Bradshaw.

  • Photography Consent & Release: I, the undersigned, consent to my image being taken and used and reproduced in any format. I understand that my image may be used for the purposes of documentation, display, publicity and in promotional materials by Waxed Skincare & Beauty Lounge. I understand that any intellectual property, including copyright and image rights, which arises in the visual image(s) belongs to Waxed Skincare and Beauty Lounge.

    Late/Cancellation Policy: If you arrive after your scheduled appointment time, it may not be possible to extend the time available for your booked service; if your service is shortened due to your late arrival, you may still be charged the full cost of the service. 24 hours’ notice is required to reschedule or cancel a booked appointment. Any reschedule/cancellation within 24 hours will forfeit any deposit, full service amount, gift certificate or special offer. 

    I agree to the policies described above.

    Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible.

    I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

    I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.

    I consent to the terms of this agreement. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

  • Date
     / /
  •  
  • Should be Empty: