Facial Intake Form

Appointment Date*

MonthDayYear

Appointment Time AM/PM Option
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Emergency Contact *
NAME/RELATIONSHIP/TELEPHONE #
Your Occupation
How did you hear about us?
Social Media, Word of Mouth, etc.
List any medications, supplements, or herbal remedies you currently take:*
If this does not apply to you, please type “N/A”
Please list allergies or sensitivities:*
If none please type “N/A”
Do you wear Contact Lens?
Preferred Massage Pressure?
(LIGHT, MODERATE, DEEP)
What are your specific concerns at this time regarding your skin or body?
What is your stress level right now?

LowAverageSomewhat StressedVery Stressed
Please list Injuries or surgeries:*
If this doesn’t apply to you please type, “N/A”
Have you ever received professional skin care treatments or massage?
What do you consider your skin type? (For facials only)

NormalOilyAcneDryAgingCombinationSensitiveRosaceaOther
What is your daily skin care regimen? (For Facials Only)
What is your goal for this session?
Please check all that apply.*

Birth ControlPregnantPostpartumBack PainHeadachesHepatitisHerpesNeck PainKnee/Leg PainHigh Blood PressureBruise EasilyDiabetesSeizuresJaw Pain / Clenching/ GrindingMetal bone, pins, or platesFibromyalgiaUsed Retin -A within the past 10 days?AsthmaLupusPaceMakerSinus ProblemsSkin DiseasesEczemaEpilepsyImmune DisordersNone of the aboveOther
By SUBMITTING THIS FORM, you agree to the following:1) I give my permission to receive massage, facials or waxing services.2) I understand that therapeutic massage is not a substitute for traditional medicaltreatment or medications.3) I understand that the therapist or esthetician does not diagnose illnesses or injuries,or prescribe medications.4) I have clearance from my physician to receive facials and massage therapy.5) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:• Superficial bruising or redness• Short-term muscle soreness• Exacerbation of undiscovered injury. I, therefore, release the individual therapist or esthetician from all liability concerning these injuries that may occur during the massage session.6) I understand the importance of informing my therapist of all medicalconditions and medications I am taking, and to let the massage therapist knowabout any changes to these. I understand that there may be additional risksbased on my physical condition.7) I understand that it is my responsibility to inform my therapist or esthetician of anydiscomfort I may feel during the session so he/she may adjustaccordingly.8) I understand that I or the therapist may terminate the session at anytime.9) I have been given a chance to ask questions about the sessionand my questions have been answered.
Signature*

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