Client Check In
Please fill out this form in it's entirety.
Client's Name
*
First Name
Last Name
Service you are receiving today (Check all that apply).
*
IV Drip Bar: Acne, Brightening, Collagen & Anti-Aging Infusions (Coming Soon)
Signature Facial
Hydrating or Acne Facial
Dermaplaning Facial
Chemical Peel
Laser Facial
Microchanneling
Microcurrent Skin Tightening
Microcurrent Eye Lift (Add-on)
Laser Hair Removal
Bikini Laser Hair Removal
Brazilian Laser Hair Removal
Body Laser Hair Removal
Skin Irregularity Treatment
Hydrating Back Facial
Back Peel
Other
Other
Your Health
Have there been any changes to your health since your last appointment (including pregnancy, surgeries, etc.)
*
No
Yes
If yes, please explain.
Have you been prescribed any new medications since your last appointment? If yes, please list.
*
No
Yes
If yes, please list any NEW medications or supplements below.
Your Skin
Have you waxed or shaved in the treatment area within the last 7 days?
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No
Yes
Have you received any of the following treatments in the last 7 days? (Check all that apply)
*
Botox
Laser Hair Removal
None
Do you have any NEW skin concerns at the moment?
*
No
Yes
If yes, please explain.
Have you used any products or services NOT recommended by your Esthetician since your last appointment?
*
No
Yes
N/a - if not receiving any skin treatments today
If you answered "yes", please list those products and/or services below:
I confirm that I have been adhering to my recommended homecare and/or aftercare.
*
No
Yes
N/a - if not receiving any skin treatments today
Add any additional notes here:
I confirm that the information I have provided is accurate and complete. I understand that withholding relevant information may affect my treatment results, and I will not hold my Esthetician responsible for any adverse reactions. Marketing use will always require separate permission. I consent to Crystal Ngozi Beauty & Esthetics and its affiliates using my photos to monitor my progress and support future skincare research and technology development. Any data shared with partners will always be de-identified and will never include my name or personal details.I understand that this consent applies to all images captured during my treatments, including past and future appointments. By checking “I agree,” I acknowledge and accept all terms.
*
I agree
Submit
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