TBR Facial Form

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Have you had a facial before?*

YESNO

What are your specific skincare concerns?

*If you have acne: I understand The Beauty Room's 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 understandNot applicable

Any other reasons for a facial besides your concerns?

RelaxationSkincare EducationHelp with What is Best for My Skin

Give us an idea of what you typically use on your skin daily?*

Any known allergies?*

The Beauty Room uses 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?

YESNO

Are you currently using any products that contain:

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 monthYES, within the last 2-3 monthsNO

Have you had botox in the past 7 days?

YesNo

Have you had fillers in the past 14 days?

YesNo

Have you experiences any of these health conditions in the past or present?

Are you taking birth control?

YESNO

Are you pregnant or breast-feeding?

YESNO

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 skin theory 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 The Beauty Room do not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from The Beauty Room. I hereby release, discharge and waive any and all claims against The Beauty Room and each of their partners, employees, representatives or any person(s) performing services or applying any products at The Beauty Room, 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.

By SUBMITTING THIS FORM, you agree to the following:

I give my permission to receive massage, facials or waxing services. I understand that therapeutic massage is not a substitute for traditional medical treatment or medications. I understand that the therapist or esthetician does not diagnose illnesses or injuries, or prescribe medications. I have clearance from my physician to receive facials and massage therapy. I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

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

Signature

Date*

Date

Facial Intake Form

Your Skin

Your Medical History

Females Clients