Facial Form

Please fill out completely
Name*

First NameLast Name
Have you had a facial before?*

YESNO
Have you ever had any issues with your previous facials?*

YESNO
What are your specific skincare concerns you would like the Oxygen to help with today?*

Dry Flakey SkinBreakoutsWrinklesBlackheadsAcneLoss of FirmnessSkin TextureLarge PoresRednessSkin SensitivityRosaceaOily SkinFine LinesNone of the aboveNone of the above
Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO
Are you currently using any products that contain:*

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsPrescriptive creams or meds for skin?
Do you currently have any rashes, itching or underlying redness on your face?*

YESNO
Your Medical History
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/Essential oilsTree NutsDairySunscreenPollenNone
Are you taking birth control?*

YESNO
Are you on accutane?

Yes (Please note we may not be able to do a treatment)No
Acknowledgement and Waiver

I hereby agree to have this treatment. I am aware that even with natural ingredients there is a rare chance of a reaction (skin redness, swelling) and there is a possibility of an adverse reaction to product used in facials.

I am also aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed to the staff at Glitz Spray Tanning all my known medical conditions, skin conditions, allergies, medications and answered all questions honestly on the above form. It is my responsibiliy to disclose all medical, and skin history, as Glitz Spray Tanning will not be responsible to reactions caused by undisclosed medical history.

I understand everyones result vary.

By signing below, I confirm that I have read and understand the above information and agree to undergo the treatment.
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Your Medical History