Facial & Skin Needling Form

Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Your Skin
Have you had a facial before?*

YESNO
What are your specific skincare concerns?

Dry Flakey SkinBreakoutsWrinklesBlackheadsAcne*Loss of FirmnessClogged PoresSkin TextureLarge PoresHyper-Pigmentation / Uneven Skin ToneRednessSkin SensitivityRosaceaOily SkinMiliaFine LinesOther
*If you have acne: I understand The Face Studio’s corrective facials will only help clear out congestion and some current blemishes. It will not prevent future congestion or blemishes. If you need help clearing acne, we have an acne program and can schedule you for a acne clearing program first time consultation at a later date.

I understandNot applicable
Any other reasons for a facial besides your concerns?

RelaxationSkincare EducationHelp with What is Best for My Skin
Give us an idea of what you typically use on your skin daily?*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)
Any known allergies?*

AsprinLatexFruitsShellfishLidocaneFragrance/Essential oilsTree NutsDairySunscreenPollenNoneOther
Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

YESNO
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubsPrescription Topicals
Do you currently have any rashes, itching or underlying redness on your face?
Please list medications or supplements you are currently taking.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO
Have you had botox in the past 7 days?

YesNo
Have you had fillers in the past 14 days?

YesNo
Your Medical History
Have you experiences any of these health conditions in the past or present?

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther
Female Clients
Are you pregnant or breast-feeding?

YESNO
Acknowledgement and Waiver

I hereby agree to have this treatment be performed on me. I am aware that products used in facials and homecare can contain tree nuts, dairy and gluten. I acknowledge that the estheticians at The Face Studio may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials.

I am also aware that certain services should not be performed with certain medical conditions. I have disclosed all my known medical conditions, allergies, medications and answered all questions honestly on the above form and agree to update The Face Studio as to any changes.

I acknowledge that the estheticians and staff at The Face Studio do not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from The Face Studio. I hereby release, discharge and waive any and all claims against The Face Studio and each of their partners, employees, representatives or any person(s) performing services or applying any products at The Face Studio, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.
Signature
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Your Skin

Your Medical History

Female Clients