Elena G Beauty

Date

Full Name

First NameLast Name

Date of Birth

Email

example@example.com

Phone Number

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Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.

How did you hear about us?

If referred, by who?

Are you currently under the care of a physician?

YesNo

Please list any medications that you are currently taking

Please list any supplements that you are currently taking

Do you have any medical conditions?

DiabetesHeart ConditionsSkin Disorders

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

Any known allergies?

Have you ever received any Botox or fillers? If so, where and when?

Have you ever experienced claustrophobia?

YesNo

Please list your stress level

LowMediumHighNone

What are your skincare goals?

Clearer SkinReduce wrinklesHydration

What is your skin type?

Normal (No visible blemishes, fine pores, smooth texture)Sensitive (Reactive to fragrance, often irritated)Combination (Oily and dry patches, oily t-zone, hormonal breakouts)Oily (Enlarged pores, excessive oil)Acne (Cystic or Nodules)Dry (Dull, visible lines and wrinkles, feels tight)

What is your primary skin concern? (e.g., Acne, Aging, Dryness, Hyperpigmentation)

Have you ever had a professional facial treatment before?

YesNo

Have you ever experienced an adverse reaction to a skincare product or treatment?

YesNo

If so, which skincare product or treatment did you experience an adverse reaction? (Please list)

What is your current skincare routine? (Products and Frequency)

What skin care products do you include in your skincare routine?

Do you currently use

AccutaneRetin-APrescribed topical/cream

Do you experience any breakouts or acne?

YesNo

Have you been diagnosed with eczema, psoriasis, or rosacea?

YesNo

Have you received any of these facial hair removal services in the last 7 days?

Waxing/SugaringThreadingLaser/Electrolysis

Have you ever received Chemical peels, Laser Services, or microdermabrasion treatments?

YesNo

How much water do you drink daily?

What is your typical daily stress level? (Low, Moderate, High)

Do you?

Do you exercise regularly?

YesNo

Are you taking birth control?

YesNo

Are you pregnant or breastfeeding?

YesNo

Do you consent to photos/videos being taken before and after the treatment for documentation and marketing purposes?

YesNo

Do you have any preferences regarding the pressure level during the facial massage?

LightMediumFirm

During your appointment to ensure a personalized and comfortable experience, do you prefer a more silent experience for relaxation or a pampering session with conversation and guidance? Please select your preference

Silent and relaxingPampering with conversationNo preference

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledgethat if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10:00am-2:00pm.

I acknowledge that this treatment is a strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, agressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I release Elena G Beauty of any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products.

Signature

Elena G Beauty

Personal Information

Medical History

Skincare Goals

Skin History

Lifestyle Questions

Female Clients

Consent and Preferences

Acknowledgement and sign below: