CUSTOMIZED FACIAL INTAKE FORM

CUSTOMIZED FACIAL INTAKE FORM

For New or First Time Facial
Name *

First NameLast Name
Birth Date*

MonthDayYear
Email*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Website/ Online SearchFacebookInstagramReferralStudio SpecialOther
If Referral or Other, please list name
Your Skin Health and History
What would you like to achieve from your treatment?*
SoapSPFTonerMaskEye ProductCleanserDay MoisturizerExfoliatorScrubsOther
What’s your current skincare routine? Please Describe*
Please list any allergies you have?*
Breakouts/acneBlackheads/whiteheadsExcessive oil/shineRosaceaRedness/ruddinessSun spot/liver spot/brown spot EyesUneven skin toneSun damageWrinkles/fine linesDull/dry skinFlaky skinDehydrated
Combination skinOily in T-zone, dry to normal cheekOily skinDry skinSensitive skin
Always BurnUsually BurnSometimes BurnRarely BurnNever burn
YesNo
If yes, when was your most recent treatment (month and year)*
Chemical peel or peel seriesLaser TreatmentsLED Light TherapyMirconeedlingDermaplaneMicrodermabrasionNone
Your Health
Hormone imbalanceCancer/ systemic diseaseHigh or low blood pressureDiabetesskin disorder/diseaseheart problemsarthritisAuto- immune disordersasthmahypertensionEpilepsy/ seizure disorderfever blistersherpesfrequent cold soresHIV/AIDSlupusdepression/anxietyhepatitisheadache/migrainesothernone
If you checked YES to any of these please provide further information. If not Mark, NA
Please rate your current level of stress:*

1

2

3

4

5

6

7

8

9

10

1 is Very Chilled, 10 is Very stressed
YesNoRecently had a baby and am breastfeedingN/A
I understand, have read and completed this questionnaire truthfully. I agree that this constituents full disclosure, and that it's supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result a irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Karina's Beauty Spa LLC and all affiliated skin care professionals from liability in assume full responsibility thereof.*

Yes
Yes
Yes
Signature*
Date*

MonthDayYear
Date
Should be Empty:

CUSTOMIZED FACIAL INTAKE FORM

Your Skin Health and History

Your Health