Facials Intake Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone#
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Emergency Contact Name
Phone#
Format: (000) 000-0000.
How did you hear about us?
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Health & Skin Screening
Do you have any known allergies or sensitivities to skincare products, cosmetics, ingredients, adhesives, latex, or topical products?
*
Yes
No
Do you currently have redness, irritation, rash, sunburn, open wounds, broken skin, active infection, cold sores, dermatitis, eczema, psoriasis, or another active skin condition in the treatment area?
*
Yes
No
Are you currently using Retin-A/tretinoin, retinol, retinal, adapalene, tazarotene, or another prescription or over-the-counter retinoid?
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Yes
No
Are you currently taking, or have you recently taken, Accutane/isotretinoin?
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Yes
No
If yes, when was your last dose?
Are you currently using AHA/BHA acids, glycolic acid, salicylic acid, benzoyl peroxide, hydroquinone, exfoliating products, or other active skincare ingredients?
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Yes
No
Are you currently using any prescription medication or topical medication that affects your skin, healing, sensitivity, or response to treatment?
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Yes
No
Have you recently had a chemical peel, laser treatment, IPL, microneedling, microdermabrasion, dermaplaning, waxing, or other resurfacing/exfoliating treatment?
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Yes
No
If yes, when?
Have you recently received Botox, dermal filler, threads, permanent makeup, or another cosmetic procedure in the treatment area?
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Yes
No
If yes, when?
Have you had significant sun exposure, tanning-bed exposure, or a sunburn recently?
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Yes
No
Do you have a history of cold sores/fever blisters (HSV) on or around the face?
*
Yes
No
Do you have a history of keloids, abnormal scarring, hyperpigmentation, or hypopigmentation following skin treatments or injuries?
*
Yes
No
Do you have diabetes, impaired wound healing, a bleeding disorder, or another medical condition that may affect your skin or healing?
*
Yes
No
Are you taking blood thinners or medications that may increase bruising, bleeding, photosensitivity, or skin sensitivity?
*
Yes
No
Are you currently pregnant or breastfeeding? (Certain products or treatment modalities may be modified or avoided.)
*
Yes
No
Have you ever experienced an allergic reaction, burn, excessive peeling, prolonged redness, pigmentation change, or other significant reaction following a facial or skincare treatment?
*
Yes
No
Have you had any recent changes in your skin, including unusual breakouts, excessive dryness, sensitivity, itching, swelling, or unexplained lesions?
*
Yes
No
Is there anything regarding your health, medications, allergies, skincare products, skin conditions, or recent treatments that your esthetician should know before performing your facial?
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Important Information
What type of skin do you have?
*
Normal
Oily
Dry
Combination
Unsure
What concerns do you have regarding your skin? Please select all that apply:
Acne/ Breakouts
Age Spots
Aging
Blackheads/Whiteheads
Broken Capillaries
Clogged Pores
Dark Eye Circles
Dark Spots
Dull/Dry Skin
Enlarged Pores
Excessive Oil/Shine
Hyperpigmentation
Redness
Rosacea
Scarring
Sun Damage
Uneven Skin Tone
Wrinkles/Fine Lines
Other
What are your short term skin goals?
What are your long term skin goals?
What is your skin care routine currently? Please list all products and brands.
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Consent Form
I hereby consent to and authorize Lancaster’s Luxe Lashes to perform the following procedure:
*
I understand that facial treatments may include cleansing, exfoliation, extractions, masks, enzymes, steam, massage, serums, topical skincare products, LED therapy, or other modalities appropriate for my skin and the facial booked.
I understand that temporary reactions may include redness, dryness, tightness, sensitivity, tenderness, irritation, peeling, purging/breakouts, swelling, or temporary changes in the appearance of my skin.
I understand that certain ingredients, medications, skincare products, recent procedures, and sun exposure can increase skin sensitivity and the risk of irritation or adverse reactions.
I understand that extractions may cause temporary redness, tenderness, swelling, pinpoint bleeding, bruising, or post-inflammatory pigmentation, particularly in sensitive or inflamed skin.
I understand that skincare products may cause an allergic or sensitivity reaction even if I have previously used similar products without a problem.
I understand that my esthetician will evaluate my skin and may modify, substitute, omit, discontinue, postpone, or refuse any portion of the treatment based on my skin's condition and response.
I understand that skincare results vary based on my skin type, skin condition, lifestyle, medications, hormones, home-care routine, sun exposure, and consistency with recommended treatments. Specific results cannot be guaranteed.
I agree to immediately inform my esthetician if I experience burning, stinging, itching, pain, excessive heat, or significant discomfort during my treatment.
I confirm that I have disclosed relevant medical conditions, medications, allergies, skincare products, recent procedures, and previous reactions.
I understand the importance of following recommended aftercare and sun-protection instructions following my facial.
I have had the opportunity to ask questions and voluntarily consent to receiving my facial treatment and the appropriate products and modalities selected for my skin.
By signing below, I acknowledge there is a no-refund policy in place. By paying for my service at the completion, I am acknowledging that I am satisfied with my services provided and credit card disputes will then be considered frivolous.
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
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Take Photo
*
Name Printed
*
Signature
*
Submit
Geolocation
*
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