Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
How did you hear about Edge Salon & Wellness?
*
Website / Online Search
Google
Facebook/Instagram
Referral
Other
If Referral, please list name
If Other, please let us know
Who is your Service Provider for upcoming reservation?
Have you used any Alpha Hydroxy Acid (ex. glycolic, lactic, etc.) acid (BHA) a facial scrub, or Hydroquinone products in the past 48-72 hours?
Yes
No
Are you currently on Retin-a, Retinol, Renova, or Accutane (an oral form of Retin-a) or Trentonin?
Yes
No
Do you wear contact lenses?
Yes
No
Have you done any hair removal (waxing, sugaring, laser/electrolysis, threading, dermaplaning) in the last 3-7 days?
Yes
No
Are you pregnant or breastfeeding?
Yes
No
Do you have any known allergies (i.e. shellfish, caffeine, citrus, almonds) If yes, please list below.
Yes
No
Please list allergies:
Have you had a Hydrafacial/ DiamondGlow before? If Yes, Please list which one.
Yes
No
Other
What are your skin challenges?
*
Oily
Redness
Ageing
Puffy or dark eyes
Dryness
Acne
Age spots
Blackheads
Dull complexion
Large pores
Rough/Uneven texture
Sensitivities
Sun Damage
Wrinkles
Whiteheads
Other
Do you have any of these health conditions?
*
Cancer
Diabetes
Epilepsy
Lupus/Autoimmune disease
High Blood Pressure
Pacemakers
History of Cold sores
No
Other
What skin care products are you using now?
What are your long term skin care goals?
What type of pressure do you prefer?
Firm
Moderate
Light
Other
By signing below, you agree to the following:
I have completed this form to the best of my ability and agree to inform the technician of any changes to the above information today and in future services. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) and/or allergies that would make the requested treatment unsuitable. I acknowledge that my skin may experience redness or irritation which usually dissipates within 72 hours after the service. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I acknowledge that this experience is not a medical procedure and does not include guaranteed results. I consent (to the best of my knowledge) that my responses to the questions above are correct and that I have not withheld any information from my service provider. I agree to waive all liabilities toward my technician and their employer for any injury or damage incurred due to any misrepresentation of my health history.
Thank you for choosing Edge Salon & Wellness!
We thank you for taking the this time so we can provide you with an exceptional service!
Signature
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Facial Intake Form
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