Facial Intake Form

Facial Intake Form
Please take the time to fully review and answer all questions on this form.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday*

MonthDayYear
Date
How did you find Kempt Esthetics?*
Were you referred by anyone? If so, who?
YES, and CAN post on social mediaYES, but NOT post on social media (before and after pictures for progress)None at all
Have you ever received a professional skincare treatment?*
NormalCombinationOilyAcneAgingDrySensitiveRosaceaOther
RosceaPosriasisEczemaAcneRetin-AAccutanePregnantPostpartumHeart ConditionsRashesArthritisEpilepsyFever BlistersHIVLupusAny metals in the bodyBruise easilyAnemicHeadachesUsed Retin-A in the past 10 daysFacial botox/FillersNeck PainBack PainCystic AcneNone applyOther
Do you have an Auto-immune Disease?*
If so, please explain.
Please list any oral/topical medications:*
If any, please list.
Please list allergies or sensitivities:*
YES PLEASE!I'D PREFER FACE ONLY
My current skincare includes...*
please list all that you currently use in your routine.
Acne breakoutsBalanced skinHyper pigmentationHypo pigmenationRednessBlackheadsAcne ScaringAging, Wrinkles, FinelinesLack of firmnessSun DamagePreventative CareMelasma aka "pregnancy mask"Pore sizeWedding prepTextureDull looking skin
I understand, acknowledge and agree that I have provided all relevant information regarding my medical history and health conditions. I agree that the esthetician is not responsible for any doctor co-pays or bills that may occur after the procedure. I am over the age of 18 years old. I have come to this location at my own free will. I understand this consent agreement is legal and binding and I will hold Kyana Bailey and Kempt Esthetics harmless from any liability that may result from this treatment. By signing below, I agree to the terms listed above.

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Facial Intake Form

Please take the time to fully review and answer all questions on this form.