New Client Facial Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Do you preferred to be contacted via e-mail or text message?* This field is required.You will be contacted within the next 24 hours with a link to book
Email
Text Message
5
What is your birthday?* This field is required.
Date
Year
Month
Day
6
Address* This field is required.Your skin care products will be shipped directly to you after your service. Please add the address where you would like to receive your mail.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Miss C Aesthetics

Please read below to learn which luxury consultation and facial services are best for you.

VIP Consultation & New Client Facial Package ($195): Includes a lifestyle, skin, and diet analysis, and we will discuss your current skincare products and desired skin care goals. You will receive a detailed plan of services/treatments that we will do over the next five months. You will have your personalized skincare products (for example cleanser, moisturizer, toner, and sunscreen) shipped directly to your home at no additional cost. You will receive an "After Facial Care Guide" to take home directly after the service.

Elite Consultation & New Client Facial Package ($240): Includes a lifestyle, skin, and diet analysis, and we will discuss your current skincare products and desired skincare goals while you are offered a drink to sip on during the consultation. You will receive a detailed plan of services/treatments that will be done over the next five months. You will have your personalized skincare products (for example cleanser, moisturizer, toner, and sunscreen), t-shirt, and custom water bottle shipped directly to your home at no additional cost. You will receive an "After Facial Care Guide" and product samples to take home directly after the service.
8
New Client Consultation & Custom Facial Package* This field is required.Please select the consultation service that you are most interested in.
VIP Consultation & New Client Facial Package
Elite Consultation & New Client Facial Package
9
Have you had a facial in the past 60 days?* This field is required.
YESNO
10
What do you feel like your current skin's condition is?Miss C Aesthetics specializes in dry/dull skin and hyperpigmentation (dark spots).
Dry Skin
Normal
Oily Skin
Combination
Mild Acne
Mature/Aging
11
You may upload a picture of your skin concerns for later assessment.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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12
What are your desired skin care goals?* This field is required.Are you more concerned with reducing hyperpigmentation, adding moisture to your dry skin, having a more youthful appearance, etc?
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Large
Normal
Small
Ok
Ok
13
What skin care products are you currently using?* This field is required.Please include if you are taking any vitamins or supplements, as well.
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Large
Normal
Small
Ok
Ok
14
By virtually signing and submitting this form, I acknowledge that I would like to be contacted in regards to a facial appointment with Miss C Aesthetics.* This field is required.
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