Online Intake Form

Online Intake Form

Please take a moment to carefully read and complete this form. Sign where indicated.
Name

First Name Last Name
Birthday

Month Day Year
Date
Email
example@example.com
Phone Number
Address

Street Address

Apt/Unit

City State / Province

Postal / Zip Code
Occupation
Reason for booking a service today? Check all that apply.

Relaxation Health and Wellness Special Occasion
How did you hear about us?

Facebook Instagram Google Word or Mouth Friend or Relative Website
This intake form is used to evaluate your individual service needs. We will maintain the confidentiality of this information, and will disclose this information only: (i) to our staff members, (ii) to quality assurance and quality control personnel, (iii) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.
Let’s get personal!

Please answer these questions to help us provide the best service for you.
Your Health
Are you experiencing any of the following health conditions? Check all that apply.

Pregnant/Trying to become Pregnant Cancer HIV/AIDS Herpes Simplex (cold sore) Hepatitis Autoimmune Disease Diabetes Heart Problems Headaches Thyroid Issues Hormone imbalance High/Low Blood Pressure Back/Neck/Shoulder Pain Eczema/Dermatitis None
Do you have any other health condition(s) not mentioned here?

YES NO
Please specify
Within the last year, have you had any health problems that have affected or could affect your skin?

YES NO
Please specify
List any medications, supplements, vitamins, diuretics, slimming pills, oral contraceptives, Isotretinoin, etc. that you take regularly. If None, type None
Are you using any topical prescriptions from a physician?

YES NO
Please specify
Do you wear contact lenses?

YES NO
I ask that you please remove before any facial service.
Do you have metal implants, a pacemaker or body piercings?

YES NO
Please specify
Do you have any allergies, including foods, skin products or ingredients, animals, etc.?

YES NO
Please specify
Do you have any sinus problems?

YES NO
Have you ever experienced claustrophobia?

YES NO
Skin Care
What current skin conditions are you currently concerned with? Check all that apply.

Acne Blackheads/Congestion Hyperpigmentation (Dark Spots) Sensitivity/Redness Dryness/Dehydration Fine Lines and/or Wrinkles Rosacea
What are your specific concerns/challenges with your skin?
How long have you been struggling with these concerns/challenges?
What skin care products are you currently using? Check all that apply.

Soap Cleanser Toner Moisturizer Masque Exfoliant Eye Products
Have you had any chemical peels, microdermabrasion or any resurfacing treatments within the last month?

YES NO
Have you had any dermaplaning, microneedling, Botox, injectables, dermal fillers or any other advanced facial or cosmetic treatments within the last month?

YES NO
Please Specify
Have you experienced sensitivity from any skincare products?

YES NO
Please Specify
Are you currently or have you ever experienced bouts of skin blotching, burning or itching?

YES NO
Please Specify
Have you been waxed or shaved your face within the last 72 hours?

YES NO
Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?

YES NO
What is the product and when was the last date used:
Have you ever/are you currently using Accutane® (acne medication)?

YES NO
When was the last date used:
Are you currently using any products that contain the following ingredients?

Glycolic Acid Lactic Acid Any Exfoliating Scrubs Hydroxy Acids (AHAs, BHAs) Vitamin A derivatives (i.e., Retinol) None
Please specify if any of the following apply to you:

Pregnant Trying to become pregnant Lactating Menstruating Pre-menstrual N/A
Is there anything else you would like us to know?
Have you ever received a professional facial?

YES NO
When was the last date of service:
COVID-19 Consent and Liability Waiver

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Beautycology Skin Care can not guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that, because skin care services involve maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive skin care services from the practitioner.
I knowingly and willingly consent to facial services(s) during the COVID-19 pandemic. *
Photo and Video Release

Before and after pictures may be taken to track your skin's progress.
I give my permission for Beautycology Skin Care to post any videos or photos of services performed on me and any information regarding the services that I have received to its social media sites including its website, Instagram and Facebook.

YES NO
- I have not had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days.
- I have not experienced any cold or flu-like symptoms within the last 14 days, including but not limited to shortness of breath or difficulty breathing, cough, fever, sore throat or any respiratory illness.
- I have not traveled outside of the United States or outside of my state of residence in the past 14 days.
- I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
- I have read and fully understand the above paragraphs and I understand the services being rendered and accept the risks.
Please type your name

First Name Last Name
Today's Date

Month Day Year
Date
Cancelation and Consent Policy:

We require all our new clients to fill out our consent form.
All appointments will not be reserved until we receive a signed consent form and a 50% deposit and is NON-REFUNDABLE.

Should you need to cancel or reschedule your appointment,
please note the following policy:
A 48-hour notice is required for any
SINGLE treatment or MULTIPLE services.

CANCELLATION OR RESCHEDULING FEES:
All appointments not cancelled or rescheduled within the 48hr time frame will be assessed a 50% charge fee of the service cost.
(NO 24hr or Same day cancellation.)

Same day cancellations or NO CALL NO SHOW
will be assessed a 100% charge fee of the service cost. Treatment Deals will also be redeemed in lieu of your absence.

Thank you
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Online Intake Form

Let’s get personal!

Your Health

Skin Care

COVID-19 Consent and Liability Waiver

Photo and Video Release