• Facial Intake Form

    Facial Intake Form

    Please fill out questionnaire
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  • Your Skin

  • Have you had a facial before?*
  • What are your specific skincare concerns?

  • *If you have acne: I understand Skins Beauty Vault corrective facials will only help clear out congestion and some current blemishes.  It will not prevent future congestion or blemishes.  I am aware that i am responsible for my at home skin care regimen to help maintain my skin.
  • 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:
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  • Have you ever received chemical peels, laser services, or microdermabrasion treatments?
  • Have you had botox in the past 7 days?
  • Have you had fillers in the past 14 days?

  • Your Medical History

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

  • Females Clients

  • Are you taking birth control?
  • Are you pregnant or breast-feeding?

  • CONSENT FORM

     

    I hereby consent to and authorize Skins Beauty Vault to perform the following procedures. 

    I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risk and hazards involved by Skins Beauty Vault

    Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guarenteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an addtional cost.

    I have read and understand the post-treatment  home care instructions. I understand how important it to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care. I will consult the esthetician immediately.

    I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

    I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthecian , whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

  • Should be Empty: