NEW CLIENT Intake Form

1
Name* Oops! This field is required in order to safely and properly serve you.
First Name
Last Name
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Cell Phone Number* Oops! This field is required in order to safely and properly serve you.(no landlines, please)
Area Code
Phone Number
3
Email * Oops! This field is required in order to safely and properly serve you.
example@example.com
4
Birth Date * Oops! This field is required in order to safely and properly serve you.
mm/dd/yyyy
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Emergency Contact Name* Oops! This field is required in order to safely and properly serve you.
First Name
Last Name
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Emergency Contact Number* Oops! This field is required in order to safely and properly serve you.
Area Code
Phone Number
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How did you discover Fabella Skin Therapy?* Oops! This field is required in order to safely and properly serve you.
Google / Online Search
I was given a Gift Certificate
Friend / Family Referral
Local Event / Auction
Social Media
Other
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If someone referred you or gifted you a certificate, who?
First Name
Last Name
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Which size Smock/Robe would you be most comfortable wearing?* Oops! This field is required in order to safely and properly serve you.
XS / S
M / L
XL / XXL
I prefer to not change out of my clothes.
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What skin care products do you currently use on your face? (scroll down & check all that apply)* Oops! This field is required in order to safely and properly serve you.
Cleanser / Dedicated Face Wash
Bar Soap or Whatever's in the Shower
Exfoliant (scrub or chemical AHA/BHA)
Vitamin C Serum
Other Serums
Weekly Mask
Moisturizer
Sunscreen
Eye Cream
Retinol and/or Night Creams
I don't have a skin care routine (no shame...we've all been there!)
I’d like professional help creating and/or refining my skin care routine.
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Are you currently using any form of retinol, including night creams?* Oops! This field is required in order to safely and properly serve you.
Yes, I use prescription retinol from the dermatologist (I will pause use of the Rx 2-3 days before my treatment)
Yes, I use over-the-counter retinol (I will pause use of the OTC 2-3 days before my treatment)
No
Not sure…what is retinol?
Other
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These days my skin is… (check all that apply).* Oops! This field is required in order to safely and properly serve you.
Normal
Oily
Dry / Dehydrated
Breaking Out
Sensitive / Red
Tired / Dull
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At my next treatment, I would like to focus on... (scroll down & choose your PRIMARY concern)* Oops! This field is required in order to safely and properly serve you.
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Sensitivity / Calming
Aging Gracefully / Healthy Vibrant Skin
I just want to relax and maintain my glow!
Maybe all of it? Help!
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When was your last facial?* Oops! This field is required in order to safely and properly serve you.
Recently (4-6 weeks)
It’s been a while
I’ve never had a facial
15
Ever had a facial or skin care service you weren't happy with? If yes, tell me more...
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Have you used topical or oral prescription medication for ACNE within the past 12 months? (Accutane, etc.)* Oops! This field is required in order to safely and properly serve you.
Yes I have used Accutane or similar Rx within the past 12 months
No I have not used Accutane or similar Rx within the past 12 months
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Do you currently apply any other topical prescription medication to your face?* Oops! This field is required in order to safely and properly serve you.
Yes
No
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If yes, please describe:
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Have you had Botox or Filler within the past 2 weeks?* Oops! This field is required in order to safely and properly serve you.
Yes, I’ve had Botox or Filler within the past 2 weeks and NEED TO RESCHEDULE. (Please pause filling out this form and contact the studio to reschedule.)
No, I’ve not had Botox or Filler within the past 2 weeks.
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Do you or are you… (scroll down & check all that apply).* Oops! This field is required in order to safely and properly serve you.
Have been diagnosed with PCOS
Pregnant/Breastfeeding
Regularly smoke or vape (no judgment! But it does effect some treatment results)
Extremely claustrophobic
Wear contact lenses
Extremely sensitive to lights
Have any eye disease (glaucoma, etc)
Have metal implants or pacemaker
Had recent face/neck surgical procedures
Have an infusion port or picc line
Have low blood pressure or diabetic
Vertigo or Pots
No, none of the above.
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Are you allergic to…* Oops! This field is required in order to safely and properly serve you.
Aspirin
Bees Wax
Dairy
Fragrance / Essential Oils
Gluten in Cosmetics
Latex
Shellfish
Tree Nuts
Vegetable/Fruits
Other
No Relevant Allergies
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If other allergy, please describe.
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Large
Normal
Small
Ok
Ok
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Ever experienced negative or allergic reactions to skin care products or treatments?Please describe
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Large
Normal
Small
Ok
Ok
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And finally, what would you like me to know about your skin going into this treatment? (history, frustrations, sensitivities, reactions, goals, etc.)
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Small
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Ok
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Are you able to legally read, understand and sign liability waivers on your own?* Oops! This field is required in order to safely and properly serve you.If you are under age 18 or have a caretaker/guardian, please select "NO" and have your legal guardian sign.
YESNO
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BY CHECKING “YES” BELOW AND SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE SKIN REACTION & MEDICAL DISCLAIMER, THE CLIENT ACKNOWLEDGMENT, RELEASE & TREATMENT CONSENT, AND THE FACIAL PREP & AFTERCARE. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. (IF THE CLIENT IS UNDER 18 YEARS OF AGE, A PARENT OR LEGAL GUARDIAN MUST PROVIDE CONSENT AND SIGN ON THE CLIENT’S BEHALF.)* Oops! This field is required in order to safely and properly serve you.
YES
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SIGNATURE * Oops! This field is required in order to safely and properly serve you.
Should be Empty: