Pinkys Beauty Box Facial Intake Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Date

How did you hear about us?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Preferred Massage Pressure?

What are your specific concerns at this time regarding your skin or body?

What is your stress level right now?

LowAverageSomewhat StressedVery Stressed

Please list Injuries or surgeries:

Have you ever received professional skin care treatments or massage?

What do you consider your skin type? (For facials only)

What is your daily skin care regimen? (For Facials Only)

What is your goal for this session.

Please check all that apply.*

Signature*

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive facial services.

2) I understand that the facial service is not a substitute for traditional medical
treatment or medications.

3) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.

4) I have clearance from my physician to receive facials.

5) I understand the importance of informing my esthetician about any skin
conditions and medications I am taking, and to let the esthetician know
about any changes to these.

6) I understand that it is my responsibility to inform my esthetician of any
discomfort I may feel during the session so he/she may adjust
accordingly.

7) I understand that I or the therapist may terminate the session at any
time.

8) I have been given a chance to ask questions about the session
and my questions have been answered.

9) I release Pinkys Beauty Box and the esthetician from all liability concerning the facial session.