Online Intake Form

  • Online Intake Form

    Please take a moment to carefully read and complete this form. Sign where indicated.
  • Birthday
     - -
  • Format: (000) 000-0000.
  • Reason for booking a service today? Check all that apply.

  • How did you hear about us?

  • 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.

  • Do you have any other health condition(s) not mentioned here?
  • Within the last year, have you had any health problems that have affected or could affect your skin?
  • Are you using any topical prescriptions from a physician?
  • Do you wear contact lenses?

  • I ask that you please remove before any facial service.

  • Do you have metal implants, a pacemaker or body piercings?
  • Do you have any allergies, including foods, skin products or ingredients, animals, etc.?
  • Do you have any sinus problems?
  • Have you ever experienced claustrophobia?

  • Skin Care

  • What current skin conditions are you currently concerned with? Check all that apply.

  • What skin care products are you currently using? Check all that apply.

  • Have you had any chemical peels, microdermabrasion or any resurfacing treatments within the last month?
  • Have you had any dermaplaning, microneedling, Botox, injectables, dermal fillers or any other advanced facial or cosmetic treatments within the last month?
  • Have you experienced sensitivity from any skincare products?
  • Are you currently or have you ever experienced bouts of skin blotching, burning or itching?
  • Have you been waxed or shaved your face within the last 72 hours?
  • Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?
  • Have you ever/are you currently using Accutane® (acne medication)?
  • Are you currently using any products that contain the following ingredients?
  • Please specify if any of the following apply to you:
  • Have you ever received a professional facial?

  • 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.

  • 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.
    • 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.
  • Today's Date
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  • 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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