Facial intake Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Have you had a facial before?

What are your specific skincare concerns?

*If you have acne: I understand Lavish Lesthetics LLC 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 an acne clearing program first time consultation at a later date.

Any other reasons for a facial besides your concerns?

Give us an idea of what you typically use on your skin daily?

Any known allergies?

Lavish Lesthetics LLC uses products in our facials that may contain tree nuts, gluten and dairy or have been manufactured in a plant with these ingredients.

Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

Are you currently using any products that contain:

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?

Have you had botox in the past 7 days?

Have you had fillers in the past 14 days?

Have you experiences any of these health conditions in the past or present?

Are you taking birth control?

Are you pregnant or breast-feeding?

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 Lavish Lesthetics LLC 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 Lavish Lesthetics LLC as to any changes.

I acknowledge that Lavish Lesthetics LLC does not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from Lavish Lesthetics. I hereby release, discharge and waive any and all claims against Lavish Lesthetics LLC and each of their partners, employees, and representatives 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.

Signature

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