Facial Intake Form

  • Facial Intake Form

    To provide the safest and most personalized experience, please complete this form prior to your appointment.

  • Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?

  • Medical History

  • Are you currently under the care of a physician?
  • Do you have any medical conditions?
  • Have you experienced any of these health conditions in the past or present?
  • Any known allergies?
  • Have you ever experienced claustrophobia?
  • Please list your stress level

  • Skincare Goals

  • What are your skincare goals?

  • Skin History

  • What is your skin type?
  • Have you ever had a professional facial treatment before?
  • Have you ever experienced an adverse reaction to a skincare product or treatment?
  • What skin care products do you include in your skincare routine?
  • Do you currently use
  • Do you experience any breakouts or acne?
  • Have you been diagnosed with eczema, psoriasis, or rosacea?
  • Have you received any of these facial hair removal services in the last 7 days?
  • Have you ever received Chemical peels, Laser Services, or microdermabrasion treatments?

  • Lifestyle Questions

  • Do you?
  • Do you exercise regularly?

  • Female Clients

  • Are you taking birth control?
  • Are you pregnant or breastfeeding?

  • Consent and Preferences

  • Do you consent to photos/videos being taken before and after the treatment for documentation and marketing purposes?
  • Do you have any preferences regarding the pressure level during the facial massage?
  • 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

  • Acknowledgement and sign below:

  • 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.

  • Date
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