Intake Form

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Date

How did you hear about us?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

Preferred Massage Pressure?

What are your specific concerns at this time regarding your skin or body?

LowAverageSomewhat StressedVery Stressed

Please list Injuries or surgeries:

Have you ever received professional skin care treatments or massage?

What is your daily skin care regimen?

What is your goal for this session.

Signature*

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive a facials, brow or waxing services.
2) I understand that the esthetician (Brenda Ramirez) does not diagnose illnesses or injuries,
or prescribe medications.
3) I understand the risks associated with facials, and waxing include but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Face Haus and the individual esthetician from all liability concerning these injuries that may occur during the session.
4) I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know about any changes to these.
5) I understand that there may be additional risks
based on my physical condition.
6) I understand that it is my responsibility to inform my esthetician of any
discomfort I may feel during the session so he/she may adjust
accordingly.
7) I understand that I or the esthetocian may terminate the session at any
time.
8) I have been given a chance to ask questions about the session
and my questions have been answered.