Facial Intake Form
Please take the time to fully review and answer all questions on this form.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
-
Month
-
Day
Year
Date
How did you find Kempt Esthetics?
*
Were you referred by anyone? If so, who?
Do you consent to photos or videos of your service being taken that may be posted on social media for marketing purposes?
*
YES, and CAN post on social media
YES, but NOT post on social media (before and after pictures for progress)
None at all
Have you ever received a professional skincare treatment?
*
Please Select
Yes, Facial
No, Facial
Yes, Message
No, Message
Yes, Both
No, Either
What do you consider your skin type?
*
Normal
Combination
Oily
Acne
Aging
Dry
Sensitive
Rosacea
Other
Please check all that apply:
*
Roscea
Posriasis
Eczema
Acne
Retin-A
Accutane
Pregnant
Postpartum
Heart Conditions
Rashes
Arthritis
Epilepsy
Fever Blisters
HIV
Lupus
Any metals in the body
Bruise easily
Anemic
Headaches
Used Retin-A in the past 10 days
Facial botox/Fillers
Neck Pain
Back Pain
Cystic Acne
None apply
Other
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:
*
MOST facials include shoulder massage. Does the Esthetician have consent?
*
YES PLEASE!
I'D PREFER FACE ONLY
My current skincare includes...
*
please list all that you currently use in your routine.
What are your main skincare concerns/focuses? Please check all that apply
*
Acne breakouts
Balanced skin
Hyper pigmentation
Hypo pigmenation
Redness
Blackheads
Acne Scaring
Aging, Wrinkles, Finelines
Lack of firmness
Sun Damage
Preventative Care
Melasma aka "pregnancy mask"
Pore size
Wedding prep
Texture
Dull 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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