Corrective Facials & Express Glow Facial Intake Form

Corrective Facials & Instant Glow Intake Form
Name *

First Name Last Name
Email
example@example.com
Phone Number *

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of BirthBirthday

Month Day Year
Date
Your Skin
Have you had a facial before? *

YES NO
What are your specific skincare concerns?

Dry Flakey Skin Breakouts Wrinkles Blackheads Acne* Loss of Firmness Clogged Pores Skin Texture Large Pores Hyper-Pigmentation / Uneven Skin Tone Redness Skin Sensitivity Rosacea Oily Skin Milia Fine Lines
*If you have acne: I understand Cryo Beauty Queen's corrective facials will only help clear out congestion and some current blemishes. It will not prevent future congestion or blemishes. If you need help clearing acne, we have an acne program and can schedule you for a acne clearing program first time consultation at a later date.

I understand Not applicable
Any other reasons for a facial besides your concerns?

Relaxation Skincare Education Help with What is Best for My Skin
Give us an idea of what you typically use on your skin daily? *

Soap Cleanser Toner Serum Mask Exfoliant (physical or chemical) Eye Cream Moisturizer SPF Vitamin A (retinol)
Any known allergies? *

Asprin Latex Fruits Shellfish Lidocane Fragrance/Essential oils Tree Nuts Dairy Sunscreen Pollen None
Cryo Beauty Queen products in our facials that may contain tree nuts, gluten and dairy or have been manufactured in a plant with these ingredients. *

I understand and acknowledge this and do not have an allergy to these ingredients.
Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

YES NO
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.) BHA (salicylic acid) Vitamin A derivative (retinol/retonids) Exfoliating scrubs Prescription Topicals
Do you currently have any rashes, itching or underlying redness on your face?
Please list medications or supplements you are currently taking.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last month YES, within the last 2-3 months NO
Have you had botox in the past 7 days?

Yes No
Have you had fillers in the past 14 days?

Yes No
Your Medical History
Have you experiences any of these health conditions in the past or present?

Hormone Imbalance Cancer/ Systemic disease High Blood Pressure Diabetes Heart problem Arthritis Auto-immune Disorder Asthma Epliepsy/Seizures Cold sores HIV/AIDS Lupus Depression/Anxiety Headaches/ Migranes None
Females Clients
Are you taking birth control?

YES NO
Are you pregnant or breast-feeding?

YES NO
Acknowledgement and Waiver

I hereby agree to have this treatment be performed on me. I am aware that products used in facials and homecare can contain tree nuts, dairy and gluten. I acknowledge that the estheticians at Cryo Beauty Queen may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials.

I am also aware that certain services should not be performed with certain medical conditions. I have disclosed all my known medical conditions, allergies, medications and answered all questions honestly on the above form and agree to update Skin Theory as to any changes.

I acknowledge that the estheticians and staff at Cryo Beauty Queen do not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from Cryo Beauty Queen. I hereby release, discharge and waive any and all claims against Cryo Beauty Queen and each of their partners, employees, representatives or any person(s) performing services or applying any products at Cryo Beauty Queen, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.
Signature

Clear

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Cryo Beauty Queen has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Cryo Beauty Queen can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.
I voluntarily seek services provided by Cryo Beauty Queen and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the US in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Cryo Beauty Queen harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Cryo Beauty Queen. I understand that this release discharges Cryo Beauty Queen from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Cryo Beauty Queen. This liability waiver and release extends to the salon together with all owners, partners, and employees.
Date

Month Day Year
Date
Signature

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Corrective Facials & Instant Glow Intake Form

Your Skin

Your Medical History

Females Clients