Facial Intake Form
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Non Binary
Emergency Contact
First Name
Last Name
Emergency Contact's Phone Number
Please enter a valid phone number.
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Medical History - Check All That Apply
*
Acne
Arthritis
Asthma
Blood Disorder
Cancer
Diabetes
Eczema
Epilepsy
Fever Blisters
Heart Condition
Herpes
Hepatitis
High Blood Pressure
HIV / AIDS
Hyper Pigmentation
Hypo Pigmentation
Hysterectomy
Immune Disorders
Insomnia
Keloid Scarring
Low Blood Pressure
Lupus
Metal Bone Pins/Plates
Phlebitis, Blood Clots
Seizure Disorder
Skin Disease/Lesions
Seborrhea
Thyroid Condition
Varicose Veins
Warts
None
Are there any other conditions, not listed above:
Any known allergies?
Please list any medications you take regularly, including vitamins, herbal supplements, aspirin:
Any recent surgery, including plastic surgery?
Are you:
*
Pregnant
Trying
Neither
Breastfeeding?
*
Yes
No
Do you have any metal implants/braces/pacemaker?
Have you ever had a facial treatment before?
*
Yes
No
What would you like to achieve from your treatment today?
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Skin Care - Please check any products you currently use:
Eye make-up remover
Cleansing cream
Facial soap
Skin toner / Astringent
Body soap
Eye cream
Day cream
Night cream
Neck lotion
Hand cream
Mask
Facial scrub
Exfoliants
Body lotion
Body scrub
None
Skin History
What is your skin type?
*
Normal
Oily
Dry
Combo
Unsure
Your exposure to the sun?
*
Never
Light
Moderate
Excessive
What type of foundation do you wear?
*
Liquid
Cream
Powder
None
How does your skin heal?
*
Fast
Slow
Scars
Pigments
Do you get bruises easily?
*
No
Yes
Skin Concerns - Check all that apply:
*
Acne
Blackheads
Broken Capillaries
Comedones
Cherry Angioma
Discoloration
Dryness/Dull Skin
Eczema
Fine Lines/Wrinkles
Hyper Pigmentation
Hypo Pigmentation
Keloids
Milia
Oily Skin
Psoriasis
Redness
Rosacea
Scarring
Sensitivity
Sun Damage
Thin Skin
Unwanted Hair
Other
None
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Have you ever used acne medication? If yes, when and what kind?
*
Have you, in the last 3 months, used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products? If yes, which ones?
*
Have you received Botox, Restylane, or Collagen injections in the last 6 months? If yes, please describe:
*
I allow my Esthetician to take photos of me/my service for use on Social Media:
*
Yes
No
By signing below, you agree to the following:
I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I agree to waive all liabilities toward my technician and Zarios Hair Salon for any injury or damages incurred due to any misrepresentation of my health.
Consent to treatment:
I hereby consent to and authorize Peggy Garcia to perform a facial treatment. I have voluntarily chosen to undergo this treatment, after the nature and purpose of this treatment has been explained to me, along with any risks or hazards involved. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments to the treated areas to obtain the expected results, at an additional cost. In the event that I may have additional questions or concerns, I will consult the esthetician immediately.
Digital Signature
*
Please type your First & Last Name
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