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CUSTOMIZED FACIAL INTAKE FORM
For New or First Time Facial
Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
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November
December
Month
Please select a day
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Day
Please select a year
2024
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Year
Email
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
How did you hear about Karina’s Beauty Spa?
*
Website/ Online Search
Facebook
Instagram
Referral
Studio Special
Other
If Referral or Other, please list name
Your Skin Health and History
What would you like to achieve from your treatment?
*
What skin care products are you currently use? (Select all that apply)
*
Soap
SPF
Toner
Mask
Eye Product
Cleanser
Day Moisturizer
Exfoliator
Scrubs
Other
What’s your current skincare routine? Please Describe
*
Please list any allergies you have?
*
What areas of concern do you have regarding your Skin: (Please check any that apply )
*
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Redness/ruddiness
Sun spot/liver spot/brown spot Eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Which of the following best describes your skin type?
*
Combination skin
Oily in T-zone, dry to normal cheek
Oily skin
Dry skin
Sensitive skin
When you go out in the sun, do you...
*
Always Burn
Usually Burn
Sometimes Burn
Rarely Burn
Never burn
Have you ever had a facial or skin treatment before?
Yes
No
If yes, when was your most recent treatment (month and year)
*
Have you received any of the following facial treatments in the past 3 months?
*
Chemical peel or peel series
Laser Treatments
LED Light Therapy
Mirconeedling
Dermaplane
Microdermabrasion
None
Your Health
Do you have a history of or are you currently experiencing any of the following conditions? (Check all that apply)
*
Hormone imbalance
Cancer/ systemic disease
High or low blood pressure
Diabetes
skin disorder/disease
heart problems
arthritis
Auto- immune disorders
asthma
hypertension
Epilepsy/ seizure disorder
fever blisters
herpes
frequent cold sores
HIV/AIDS
lupus
depression/anxiety
hepatitis
headache/migraines
other
none
If you checked YES to any of these please provide further information. If not Mark, NA
Please rate your current level of stress:
*
Very Chilled
1
2
3
4
5
6
7
8
9
Very stressed
10
1 is Very Chilled, 10 is Very stressed
Are you pregnant or trying to become pregnant?
*
Yes
No
Recently had a baby and am breastfeeding
N/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
I understand if any cancellations or rescheduling with less than 24 hours of notice or no-show appointments are subject to a cancellation fee amounting to 50% of the cost of the scheduled service.
*
Yes
I understand NO REFUNDS. All purchases are FINAL SALE.
*
Yes
Signature
*
Date
*
/
Month
/
Day
Year
Date
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