Facial Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

List any medications, supplements, or herbal remedies you currently take:*

Please list allergies or sensitivities:*

Please list Injuries or surgeries:*

Have you ever received professional skin care treatments?*

What are your specific concerns at this time regarding your skin?*

What is your stress level right now?*

LowAverageSomewhat StressedVery Stressed

What do you consider your skin type?*

What is your daily skin care regimen? *

Please check all that apply.*

What is your goal for this session.

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive facials services.
2) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.
3) I have clearance from my physician to receive facials services.
4) I understand the risks associated with facials include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Dorthy Eyebrow Threading Spa Inc. and its esthetician from all liability concerning these injuries that may occur during the facial session.
5) I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
6) I understand that it is my responsibility to inform my esthetician of any
discomfort I may feel during the session so she may adjust
accordingly.
7) I understand that I or the esthetician may terminate the session at any
time.

Signature*

Date