New Customer Registration Form
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
example@example.com
What is your Date of Birth?
*
Do you have any allergies or sensitivities?
*
Do you have any skin disorders diagnosed by a doctor? (rosacea, eczema, psoriasis etc.)
*
Please list any medications you take regularly?
*
How would you describe your skin type?
*
Dry
Oily
Dry and oily
Sensitive
I do not know
What are your skincare challenges?
*
Wrinkles/Fine Lines
Hyperpigmentation/Sun Damage
Acne/Scarring
Redness/Rosacea
Melasma
Sensivity
Dehydration/Dryness
Texture
Dryness/Flaking
What is your current relationship with skincare?
*
I have a routine that works for me
I try different products every few months
I do not feel like my products are working for me
I don't know much about skincare
I need a new regimen
What is your preferred massage pressure?
*
Light
Medium
Firm
Do you wear sunscreen daily?
*
Yes
No
I would like my esthetician to:
*
Educate me through my service about products and techniques
I do not mind small talk
I would like a silent treatment
I have NO sunburn
*
I agree
I disagree, I need to reschedule
Are you currently on Accutane, or using medical grade Retinol/Retin-A?
*
Yes
No
Are you currently on or taking any birth control?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Are you claustrophobic?
Yes
No
Do you have:
*
A pacemaker
Metal Implants
Body piercings
Nothing
Have you ever received chemical peels, laser, or microdermabrasion?
*
Yes, within the last 1-3 months
No
I have NO viruses, colds, flu, fever, sores, bacterial infections, or fungal infections.
*
I agree
I disagree, I need to reschedule
I have NOT received any injectables, filler/botox, laser hair removal, or laser treatments in the past 14 days.
*
I agree
I disagree, I need to reschedule
Do you consent to the following statement? I am at least 18 years of age; I have not received botox in the last two weeks or filler in the last 4 weeks. I have been given the opportunity to ask questions about this facial have received satisfactory answers and understand the information given to me. I understand that allergic reactions to this facial are rare but possible and will contact my doctor and Graceful Radiance immediately if I have any reaction, redness, or irritation as a result of this facial. Graceful Radiance has not made any claims of medical benefits associated with this facial and I understand that this facial is not a replacement for medical services from a licensed physician.
*
I agree
I disagree
Date
*
-
Month
-
Day
Year
Date
Signature
*
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Continue
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