Facial Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Format: (000) 000-0000.

Date of Service*

Date

Date of Birth*

Date

List any medications, supplements, or herbal remedies you currently take (oral or topical) :*

Please list ANY allergies or sensitivities:*

Preferred Massage Pressure?*

(light, medium, hard)

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

LowAverageSomewhat StressedVery Stressed

Please list Injuries or surgeries:*

Have you had botox / filler / microneedling / chemical peel done in the past 2 weeks?*

Have you ever received professional skin care treatments?*

If so, did you experience any issues?

please elaborate if answered YES.

What is your daily skin care regimen?*

skin care routine

What is your goal for this session.*

What are your overall skin care goals?*

This will help determine a treatment plan going forward.

Signature*

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive the FULL SERVICE facial done by Hannah Valdez.
2) I understand that therapeutic massage is not a substitute for traditional medical
treatment or medications.
3) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.
4) I have clearance from my physician to receive facials and massage therapy.
5) I understand the risks associated with massage therapy and facials include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

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