FACIAL INTAKE FORM + LIABILITY WAIVER

Name

First NameLast Name

Date of Birth

MonthDayYear

Phone Number

Please enter a valid phone number.

Email

example@example.com

Within the last year, have you been under a dermatologist’s or other physician’s care?*

YesNo

If yes, please specify:

Have you had any health problems in the past or present?*

YesNo

If yes, please specify:

Do you have any allergies?*

YesNo

If yes, please specify:

List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly?*

Do you smoke?*

YesNo

Do you exercise regularly?*

YesNo

Do you follow a restricted diet?*

YesNo

Do you have metal implants, a pacemaker or body piercings?*

YesNo

Do you wear contact lenses?*

YesNo

Do you sunbathe or use tanning beds?*

YesNo

Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?*

YesNo

Have you ever experienced claustrophobia?*

YesNo

Rate your stress level on a scale of 1 to 5*

1 is Low, 5 is High

What are your specific concerns / challenges with your skin?*

What skin care products are you currently using on your face? Please check all that apply.*

What skin care products are you currently using on your body? Please check all that apply.*

Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?*

YesNo

If yes, in the last month?

Do you use Retin-A, Renova, Adapalene or any other prescription skin products?*

YesNo

If yes, in the last month?

Are you currently using any products that contain the following ingredients?*

Have you ever experienced the following conditions on your skin?*

FlakinessTightnessObvious drynessNone

What SPF sunscreen do you use on your face?

What SPF sunscreen do you use on your body?

Do you burn easily in moderate sunlight?*

YesNo

Do you suffer from sinus problems?*

YesNo

Do you ever experience burning, itching or stinging sensations on your skin?*

YesNo

Do you have a tendency to redness?*

YesNo

Are you taking oral contraception?*

YesNo

Are you pregnant?*

YesNo

Are you lactating?*

YesNo

Are you currently having or due for a menstrual cycle?*

YesNo

Have you started any new medications since your last visit?

YesNo

If yes, please specify:

*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.*

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposureespecially between 10am-2pm.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I acknowledge that when receiving dermaplane exfoliation treatmet a sterile surgical blade is being used.

I acknowledge that any treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

I release Luminary Aesthetics & Co. and assigned esthetician of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

*BY AGREEING TO THESE TERMS AND CONDITIONS AND SIGNING BELOW, I VERIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS AND AGREE TO THEM.

Signature

Date

FACIAL INTAKE FORM + LIABILITY WAIVER

Your Health

Your Skin