EXISTING CLIENT Intake Form

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Name* This field is required in order to safely and properly serve you.
First Name
Last Name
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Emergency Contact Name* This field is required in order to safely and properly serve you.
First Name
Last Name
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Emergency Contact Number* This field is required in order to safely and properly serve you.
Area Code
Phone Number
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What skin care products have you been using on your face lately? (scroll down & check all that apply)* 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.
Other
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Are you currently using any form of prescription or over-the-counter retinol/retinal/retinoic acid?* This field is required in order to safely and properly serve you.
Yes (I will pause use a few days before my treatment, including night creams.)
No
Not sure…what is retinol?
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These days my skin is… (check all that apply).* This field is required in order to safely and properly serve you.
Normal
Dry / Dehydrated
Oily
Breaking Out
Sensitive / Red
Tired / Dull
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Over the next few treatments, I would like to focus on... (scroll down & choose your PRIMARY goal)* This field is required in order to safely and properly serve you.
I'm interested in the brightening & firming Arctic Berry Facial Peel Series. Tell me more!
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Redness / Rosacea
Sensitivity / Calming
Acne / Acne Scarring
Aging Gracefully / Maintaining Healthy Vibrant Skin
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Have you used prescription medication for ACNE within the past 12 months? (Accutane, etc.)* 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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Have you had Botox or Filler within the past 2 weeks?* 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).* This field is required in order to safely and properly serve you.
Wear contact lenses
Pregnant / Breastfeeding
Diagnosed with PCOS by a medical professional
Sensitive to lights or other eye conditions/diseases
Have neck mobility issues
Regularly smoke or vape
Extremely claustrophobic
Have an infusion port or picc line
Had recent face/neck surgical procedures of any kind
Have metal implants
Have a pacemaker
No, none of the above
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Do you have allergies to ANYTHING, including fragrance, herbs, aspirin, anything?* This field is required in order to safely and properly serve you.
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If you experienced an allergic (or any other kind of) reaction after your last treatment at Fabella, please tell me a bit more about that:
Huge
Large
Normal
Small
Ok
Ok
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* This field is required in order to safely and properly serve you.BY CHECKING “YES” BELOW AND SIGNING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE SKIN REACTION & MEDICAL DISCLAIMER, CLIENT ACKNOWLEDGMENT, RELEASE & TREATMENT CONSENT, AND FACIAL PREP & AFTERCARE. I CERTIFY THAT THE INFORMATION PROVIDED 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.
YES
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SIGNATURE * This field is required in order to safely and properly serve you.
Should be Empty: