Facial Treatment Intake Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Medical History* This field is required.Do you have or have you had any of the following conditions? If yes, please select them:
Acne
Arthritis
Asthma
Blood Disorder
Cancer
Diabetes
Eczema
Epilepsy
Fever Blisters
Heart Conditions
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
Other
7
Do you have any known allergies?* This field is required.If yes, please give me more details in the following section. Your health and safety are my #1 priority.
YESNO
8
Please explain your allergic reaction in more detail.
Huge
Large
Normal
Small
Ok
Ok
9
List any medications you take regularly, including vitamins, herbal supplements, aspirin:* This field is required.
10
Any recent surgery, including plastic surgery?* This field is required.
YESNO
11
If yes, please explain.
12
Are you pregnant or trying to become pregnant?* This field is required.
YESNO
13
Have you ever had a facial treatment before?* This field is required.
YESNO
14
What changes would you like to see in your skin?* This field is required.
15
Skin Care* This field is required.Please check current products you use:
Eye Makeup Remover
Cleanser
Cleansing Oil
Skin Toner/Astringent
Body Soap
Eye Cream
Day Cream
Night Cream
Neck Lotion
Hand Cream
Mask
Facial Scrub
Exfoliants
Retinol
Body Lotion
Body Scrub
16
What is your skin type?* This field is required.
Normal
Dry
Oily
Combination
Unsure
17
Your exposure to the sun?* This field is required.
Never
Sometimes
Often
Excessive
18
How often do you wear foundation?* This field is required.
Never
Rarely
1-3x/week
Everyday
19
How does your skin heal?* This field is required.
Fast
Slow
Scars
Pigments
20
Do you get bruises easily?* This field is required.
YESNO
21
Skin Concerns* This field is required.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
22
Have you ever used acne medication?* This field is required.
YESNO
23
If yes, when and what type?* This field is required.
24
Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?* This field is required.
YESNO
25
If yes, please describe.* This field is required.
26
Have you received Botox, Restylane, or Collagen injections in the last 2 weeks?* This field is required.
YESNO
27
Would you like to personalize your experience with this form today?* This field is required.
YESNO
28
Which extra experience(s) would you like to treat yourself today?* This field is required.I'm happy to carry out these treatments for you today. Please note, while I will make every effort to do them, their completion may depend on our available time.
Dermaplaning (+$50)
Chemical Peel ($50)
Additional 10 minutes of massage (+$25)
Eyebrow, Lip, or Chin Wax (+15)
Nothing today, but thanks for the offer!
29
Do you have any sensitivity to fragrances, such as essential oils, candles, or room sprays?* This field is required.
YESNO
30
What kind of atmosphere would you prefer for our appointment today?* This field is required.This is your time and I want you to be as comfortable as possible.
Explain steps & products
Quiet & Relaxing
I'd like a silent appointment, I need to recharge.
No Preference
31
Among the following music options, which one do you prefer?* This field is required.
Ambient Sleep
Traditional Spa
Chill House
Classical
32
As a general inquiry, would you prefer the bed heater to be turned on for each appointment? Please note that this can always be adjusted on the day of your visit.* This field is required.
YESNO
33
Do you have any other preferences or adjustments that we can make to ensure that your experience is the best possible?
34
POLICIES* This field is required.Cancellations Stuff happens, and sometimes you need to cancel your appointment. I get it. If you need to cancel more than 48 hours before your appointment, just shoot me a message letting me know. If you don’t let me know or have to cancel less than 48 hours before your appointment, I take 50% of the appointment scheduled. If you need to cancel with less than 24 hours before your appointment, I take 75% of the appointment scheduled. Talk to me to find out more. If you cancel more than 2 appointments within 48 hours of your scheduled appointment, a non-refundable booking fee of $50 will be required for all future appointments. If your appointment is kept, the fee will go towards the remaining balance. Late Policy I understand that due to your busy schedule, you may find yourself running late. If you think you are going to be late, please reach out and let me know. If you are more than 10 minutes late, your appointment may be reopened or given away to another client. If the appointment is kept for you, I may not be able to complete the full service you booked.
I have read & agree to these terms, policies, and conditions.
35
Signature* This field is required.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 to waive all liabilities toward my technician for any injury or damages incurred due to any misrepresentation of my health history.
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