Facials & Body Treatments
Please fill out this form before your appointment
Name
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First Name
Last Name
Have you had a facial before? Was it recent?
Have you had any botox/fillers or chemicals peels in the last two weeks? If yes, please list the date below.
Do you get your face waxed? If so, please list the date of last wax:
Do you use any form of Vitamin A/Retinol or acne medications or have you been on Accutane? If so, please list the last date you took/used it.
Is your skin sensitive / reactive? Does it turn red or have a reaction when you apply products to it or get facials?
What type of skin do you have? (please check all that apply)
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Normal
Combination
Oily
Sensitive
Dry
Acne
Mature/Aging
How would you rate your skin? (please check one)
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Always burns, never tans (I)
Always burns easily, tans slightly (II)
Burns moderately, tans gradually (III)
Seldom burn, always tans well (IV)
Rarely burns, deep tan (V)
Never burns, deeply pigmented (VI)
What would you like to get from this facial or treatment?
Are you looking to treat acne? Concerned about fine lines/wrinkles? Is your skin very dry and needs hydration?
What types of products do you normally use for your skin? What is your skincare routine like?
Would you like any product recommendations at the end of your service? Are you interested in purchasing? What types of products are you interested in?
I understand that redness, sensitivity, peeling or other reactions may occur from a facial treatment. I further understand that estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and that a facial should not be a replacement for medical treatment. I understand that facial results are not guaranteed and that for maximum results, more than one treatment may be required. The rate of improvement of my skin depends on my age, skin type, condition, degree of sun/environmental damage, pigmentation levels, or acne condition. I certify that I have read this entire consent form and I understand and agree to the information provided in this form. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release Mary K Curry of Sea Breeze Beauty from liability.
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Today's Date
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Month
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Day
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Date
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