Corrective Facials & Express Glow Facial Intake Form

Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Your Skin
Have you had a facial before?*

YESNO
What are your specific skincare concerns?*

Dry SkinOily SkinFine lines/WrinklesBlackheadsAcneSkin TextureLarge PoresSun DamageRednessSensitive SkinRosaceaOther
Any other reasons for a facial besides your concerns?

RelaxationSkincare EducationProduct Recommendations
Give us an idea of what you typically use on your skin daily?

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/Essential oilsTree NutsDairySunscreenPollenNoneOther
Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

YESNO
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsPrescription Topicals
Do you currently have any rashes, itching or underlying redness on your face?
Please list medications you are currently taking.*
Have you had botox in the past 7 days?

YesNo
Have you had fillers in the past 14 days?

YesNo
Your Medical History
Have you experienced any of these health conditions in the past or present?

Hormone ImbalanceCancerDiabetesCold soresHIV/AIDSNoneOther
Females Clients
Are you pregnant or breast-feeding?

YESNO
Acknowledgement and Waiver I hereby agree to have this treatment be performed on me. I am aware that there is a chance of an allergic reaction or an adverse reaction to products used in facials. I am also aware that certain services should not be performed with certain medical conditions. I have disclosed all my known medical conditions, allergies, medications and answered all questions honestly on the above form and agree to update of any changes. I acknowledge that my esthetician does not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products. I hereby release, discharge and waive any and all claims against my esthetician performing services or applying any products, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.
Signature*

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Your Skin

Your Medical History

Females Clients