• Facial Intake Form

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Referred by?*

  • Expectations and History

  • Have you ever had a facial treatment in the past?*
  • How would you describe your skin?*
  • Do you ever experience any of the following?*
  • How would you rate your skin?*
  • Which conditions would you like to improve?*
  • Do you experience any of the following in your skin? (select what applies)*
  • What is your current skincare routine?*
  • Have you ever been exposed to an ingredient or product that has caused a reaction in your skin? A reaction that exhibited symptoms of itching, burning or needing to take allergy medication/antihistamines.*
  • Do you blush easily?*
  • Do you do any of the following?*
  • Have you ever done any of the following?*
  • Are you currently under care from a dermatologist for any skin conditions?*
  • How does your skin heal?*
  • Do you bruise easily?*
  • Do you get sore/ blisters (Herpes/Zoster/Shingles)?*
  • Have you ever used*
  • Please select the areas of the body you are comfortable receiving massage.
  • How would you describe your overall health?*
  • Have you had any of the following in the past or present?*
  • Have you ever had a reaction to any of the following?*
  • Are you on oral contraceptives?*
  • Are you currently pregnant or breastfeeding?*
  • Are you taking hormone replacement?*
  • Do you experience hormone imbalances?*
  • Do you shave your face or body with the following?*

  • Lifestyle and Diet

  • How is your stress level?*
  • Do you normally sleep well?*
  • Do you regularly exercise?*
  • Do you have any food tolerances?*
  • Do you have any follow a special diet?*

  • Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.

  • I   *   *   fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care.

    I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle.

    I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately. I release and hold the skin care professional Jordan Owens and The Lunar Cottage L.L.C harmless from any liability for adverse reactions that may result from this treatment.

  • Date*
     - -
  • Should be Empty: