Corrective Facials & Express Glow Facial Intake Form

Pink & Polished
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
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 Pink and Polished 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
Pink and Polished uses products in our facials that may contain tree nuts, gluten and dairy or have been manufactured in a plant with these ingredients.*

I understand and acknowledge this and do not have an allergy to these ingredients.
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
Females Clients
Are you taking birth control?

YESNO
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 skin theory 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 Skin Theory as to any changes.

I acknowledge that the estheticians and staff at Pink and Polished do not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from Pink and Polished. I hereby release, discharge and waive any and all claims against Pink and Polished and each of their partners, employees, representatives or any person(s) performing services or applying any products at Pink and Polished, 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.
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Pink & Polished

Your Skin

Your Medical History

Females Clients