FACIAL INTAKE FORM

Name

First NameLast Name

Date of Birth

Date

Phone

Email

How did you hear about us?

Referred by (First & Last Name) :

"NONE" if not applicable.

Have you ever had a facial treatment before?

If yes, how long ago was your treatment?

"NONE" if not applicable.

What are you hoping to get out of your facial today?

To personalize your experience, please let us know if you have any sensory preferences or sensitivites: (Select all that apply or select NONE)

Other

Are there any parts of a facial service that make you feel uncomfortable or anxious? (Example: steam, extractions, face towels, close contact, etc.)

What are your skin concern(s)?

Please select if you are on these medications:

Please list any allergies or sensitivities:

"NONE" if applicable.

Have you ever had a reaction from a product or treatment? If yes, please list:

"NONE" if not applicable.

Please list your current home skincare products:

Rows	Please list product names:
Cleanser / Soap
Toner
Serums
Moisturizer
Masks
Exfoliants / Scrubs
Sunscreens
Other
If none, type NONE

Have you had any facial or dermatology service in the past 30 days?

If yes, please explain:

Are you pregnant, nursing, or trying to conceive?

Medical History:

Rows	Yes	No
Dibetes
Herpes Simplex (Cold Sores)
Cancer
Epilepsy
Hepatitis
Immune Disorders
Lupus
Eczema
Psoriasis
Staph Infection / MRSA
Anemia
Hemophilia
Pacemaker
Hormonal Imbalance
Blood Clotting
Hepatitis A / B / C
Skin Cancer
Rosacea
Metal Implants
NONE

List any other medical history / diagnosis that were not listed above:

"NONE" If not applicable.

Have you received Botox, Restylane, Filler or Collagen injections in the last 6 months?

If yes, please specify:

Do you consent to having photos and videos taken before, after and during your service for social media/portfolio purposes?

TERMS & CONDITIONS

I confirm that all of my information in this form is true and accurate to the best of my knowledge. I confirm and understand that if I withhold important information and complications happen, this clinic will not be liable. I agree to waive all liability towards my esthetician for any injury or damages incurred due to my representation of my health. I consent NUBIA SKYN the right to take photos, videos, and audio to be used to publish any lawful promotional materials. I waive the right to inspect or approve the finished products, any royalties, or other compensation related to the use of my image and recording. I herby hold harmless and release NUBIA SKYN from liability, petitions, and courses of actions.

Policy
To maintain the highest level of service and availability for all clients, please review and acknowledge the following policies prior to booking. Cancellations or reschedules made within 72 hours of the scheduled appointment will result in a charge of 50% of the remaining service balance. Same-day cancellations, no-shows, or arrivals more than 7 minutes late will be charged 100% of the service price. All deposits are non-refundable and may be transferred one time only to a rescheduled appointment when the change is made more than 72 hours in advance. A deposit is required when rescheduling any pre-booked appointment, and appointments canceled or rescheduled within 72 hours will require a new deposit to secure a future booking. Accepted payment methods include cash (preferred, exact change) and credit/debit cards. All sales are final, no refunds will be issued, and only one promotional offer may be used per visit. By booking, you consent to receiving promotional emails and text messages.

Client Name (signature)

Date