General Intake Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date

How did you hear about us?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Please list Injuries or surgeries:

Have you ever received professional skin care treatments?

What are your specific concerns at this time regarding your skin?

What is your stress level right now?

LowAverageSomewhat StressedVery Stressed

What do you consider your skin type?

What is your daily skin care regimen?

Please check all that apply.*

What is your goal for this session.

TERMS AND CONDITIONS:

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive facial services.
2) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.
3) I have clearance from my physician to receive facials.
4) I understand the risks associated with facials that include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Lauren Jeong Esthetics and the esthetician from all liability concerning these injuries that may occur during the treatment session.
6) I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
7) I understand that it is my responsibility to inform my esthetician of any
discomfort I may feel during the session so he/she may adjust
accordingly.
8) I understand that I or the esthetician may terminate the session at any
time.
9) I have been given a chance to ask questions about the session
and my questions have been answered.

Signature*