Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is this your first facial?

How would you describe your skin type?

What are THREE main skin concerns that you have?

Are you currently Pregnant?

Are you currently taking birth control pills?

If 'Yes' what type?

Are you presently under a physician's care for any current skin condition or other problem?

Are you presently using (or have used in the past) Azlex, Differin, Renova, Retin-A, Tazarac, Glycolic or Alpha Hydroxy Acids (AHAs)?

If 'Yes', when and for how long?

Are you now using or have ever used Acutane?

Are you currently taking any medications?

If 'Yes', please list.

Are you taking or have taken oral steriods?

Do you have any of the conditions listed below? Check all that apply.

Do you have any allergies? If 'Yes' please list. (Medications, Fragrances, Ingredients, products, food)

Do you wear contact lenses?

Do you smoke?

Have you had any recent treatments? (Lasers, Botox, Filler, Hair Removal, Chemical Peels, Used tanning bed)

Do you wear sunscreen daily?

I acknowledge and agree to the following:

By signing below, I acknowledge that I have read and understand the intake and consent form. I consent to the facial treatment and comply with the aftercare instructions provided. I understand potential risks and will notify the esthetician of any changes to my health, skin, or eyes in the future.

Facial Client Intake/Consent Form