New Facial Client Intake Form

Client's Name*

First NameLast Name

Gender

MaleFemalePrefer not to sayOther

Date of Birth

Date

Phone Number*

Email Address

example@example.com

How’d you hear about us?*

GoogleSocial MediaA FriendOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any of the following conditions? If yes, please select them:

If other, Explain.

Are you allergic to anything? (Separate with comma)*

Skin condition*

NormalOilyDryCombination

Are you pregnant or breastfeeding?*

YesNo

How do you take care of your skin at home?

What skincare products and brands do you use? Be specific.

Tell me about your skincare concerns and goals?*

Are you interested in product recommendations?*

YesNo

What is your budget for products (if any)?

How often are you wanting or able to come in for treatments?*

Every 2 weeksOnce a monthOther

If other, type your answer here.

What is your budget for treatments (if any)?

Do you use Retinol in your skincare routine?*

YesNo

When was the last time you used any retinol product?*

Are you taking any contraceptive pills or use another form of birth control (ex. IUD)?

YesNo

Are you currently on any specific kind of diet?

YesNo

If yes, please explain.

What medications are you currently using/taking? Oral and topical. (Please use comma to separate)

What vitamins/supplements/powders are you currently taking/using?

Have you used (in the past 6 months) or are currently on Accutane?*

YesNo

Have you received Botox, Filler, or injections in the face or lip area in the past two weeks?*

YesNo

When was the last time you received injections such as filler, Botox, Kybella, etc..?

Are you on any blood thinning medications?*

YesNo

By signing this form I acknowledge that:

I have not been exposed to excessive sun atleast 7 days before this treatment and my skin does not feel sensitive or irritated in any way.
I have not had any chemical peel, laser, microneedling, or any advanced skin treatment of any kind, within 14-30 days of this treatment. If yes, notify your esthetician.
I have not had any facial waxing, within three-seven days of this treatment.
I have informed the clinic of all health problems of which I am aware, including herpes simplex/cold sores. A facial treatment cannot be performed if a cold sore is present. You are responsible for informing the provider and rescheduling in a timely manner if necessary.
I have informed the clinic of any use of oral or topical medications I may be using including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane.
If you've received injectables within 14 days of your facial, you will not be able to receive any facial treatment.

I acknowledge that my skin might experience temporary irritation, tightness, redness, dryness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. Please ensure to list all known allergies on the Client Intake Form. Inform your physician immediately of allergic reaction if one occurs.

I acknowledge that if I fail to use sunscreen correctly , I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure for 3 days to 2 weeks after my skin treatment. I also should especially avoid sun exposure between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products or prescriptions, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for atleast 1 week following treatment.

I consent that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Mood Skin and Body and employees of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

I understand that my data will be strictly confidential. This spa, Mood Skin & Body, does not sell, share, or resell information.

I confirm that all information in this form is true and accurate.

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

I release this spa, Mood Skin & Body, and hold harmless against any claims, expenses, damages, and liabilities.

Date Signed*

Date

Client Signature

Client Intake and consent Form

Terms & Conditions