Corrective Facials & Express Glow Facial Intake Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Have you had a facial before?

What are your specific skincare concerns?

Any other reasons for a facial besides your concerns?

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

Any known allergies?

Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

Are you currently using any products that contain:

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?

Have you had fillers in the past 14 days?

Have you experienced any of these health conditions in the past or present?

Are you pregnant or breast-feeding?

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

Your Skin

Your Medical History

Females Clients