Corrective Facials & Express Glow Facial Intake Form

Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
What are your specific skincare concerns?

Other
Which products are you currently using on your face?
Are you under the care of a Dermatologist for any skin issues pertaining to your face, neck, arms, or chest area?
Are you currently using any products that contain:
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Your Medical History
Have you experienced any of these health conditions in the past or present?

Other
Please list medications or supplements you are currently taking.
Any known allergies?

Other
Stress level?
Male Clients
Describe your current shaving routine for facial hair?
Razor, Electric, Barber Shop, Dry Shave, Use of Creams or Gels
Do you have any skin issues from shaving?
Female Clients
Are you taking birth control?
Are you pregnant or breast-feeding?
How would you like to be contacted to discuss your skin concerns?
Pictures or videos of your skin may be requested by CES to track results and/or for social media education or marketing posts. Select your level of participation below:
I agree to this information release form and I acknowledge that all information provided to Cindy Everson Skincare is correct.
Sign here: Signature
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Your Medical History