Ethos of Annapolis Facial intake form

Full Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Area CodePhone Number

E-mail*

How did you hear of Ethos of Annnapolis? *

Have you had a facial treatment before?*

What is your primary reason for today’s visit? (choose all that apply)*

RelaxationSkincare advice/problem solvingOther

Have you ever experienced an adverse reaction to any ingredients or products used during a facial treatment?*

If yes, please explain:

Please list any known allergies, including food, medicines, seasonal, etc. :*

Are you currently pregnant or breastfeeding?*

Do you become claustrophobic easily? (At times we use modalities that may cover the eyes or require a mask to set for a time over the area — please let your service provider know if they should avoid these treatments)*

Have you ever received advanced facial modalities such as chemical peels, laser treatments, or microdermabrasion? *

If yes, please list the treatment and the date received:

Have you received Botox, Restylane, Dysport, fillers or collagen injections?*

If yes, which treatments did you receive, and in which areas? (If received within the last 10-14 days, facial services must be scheduled out further.)

Do you have any skin infections or inflammatory problems (e.g. herpes, acne etc)?*

If yes, please explain:

Do you use Accutane, Retin-A (Tretinoin), Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?*

YesNo

If yes, please list which products you're currently using: (If using RX retinoids, please cease using 3-5 days prior to your visit. If using Accutane, you are contraindicated for facial services and must be off for 3-6 months before doing so)

What is your current skincare routine? Please list the products you are using.*

What areas of concern do you have regarding your skin? Where would you like to see improvement?*

I understand that as with any facial treatment, there runs the risk of some purging (blemishes emerging post-treatment). This is not guaranteed, but it is a very natural and temporary effect of a professional treatment. If you have any questions or concerns following your visit today, please reach out to us for guidance.*

I understand

I grant permission and give my consent to Ethos of Annapolis and its staff for the use of photograph(s) or electronic media images as identified below for presentation under any legal use. I understand that the images may appear on the social media pages managed or owned by the recipient and any other publication. The photos shall be limited to use for, and will not be used for any other purposes. We will not include personal details (such as full names, postal addresses, or telephone numbers). I understand I may revoke this consent at any time by contacting Ethos of Annapolis or my provider in writing.*

I consentI do not consent

Your practitioner may ask for further details regarding your responses to this questionnaire. Treatment may be refused if it is not considered in your own interest to proceed.

Sign below and click submit to complete your form.

Thank you,

Ethos of Annapolis

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