SBM FACIALS BY MALANI SKIN CURENT NEW CLIENT WAITLIST

Name:*

First NameLast Name

DOB*

Date

Phone Number:*

Please enter a valid phone number.

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about SBM?*

Walk InInstagram or Tik TokGoogle/Online searchReferral

If referred, by who?

What is your skin type?*

When was your last facial?*

Put none if this does not apply to you

What are your main concerns?*

What are your skin goals?*

Current Skin Care Routine for AM & PM (More details the better) : *

example: AM - CeraVe Cleanser, Kiehls Moisturizer, Supergoop Spf // PM - Vivant Mandelic Cleanser Olay Night cream

Do you receive Botox or Filler treatments? If so when was your last treatment.*

Put none if this not does not apply to you

Have you ever received chemical peels, laser facial treatments, or microneedling?*

NoYes, within the last monthYes, within the last 2-6 months

Do you currently use:*

Upload photos of your skin with no make up (front and both sides of face) :*

Are you currently pregnant or breastfeeding?*

List any ALLERGIES *

put none if you have no allergies

List any autoimmune disorders or health conditions*

example; lupus, cancer, pcos, endometriosis, thyroid issues, cold sores etc.

List any medications or supplements*

include any workout supplements as well

Do you smoke tobacco or vape pens?*

NoYesSocially

Do you have a pacemaker or suffer from seizures?*

NoYes

Do you have any claustrophobia issues?*

NoYes

Do you consume caffeine?*

NoYes

Saturday appointments are extremely limited and rarely available for New Client Facials. If you're a new client, I recommend booking on a Tuesday through Friday to ensure availability. Please write down below which days and times work best for you, I will try my best to accommodate. Keep in mind I am closed Sunday and Mondays.*

example: Tuesday - Thursday mornings or Friday afternoons

I acknowledge and understand the following:

The nature, purpose, and potential benefits of the treatment have been explained to me, and all of my questions have been answered to my satisfaction.
I am aware that with any skincare treatment, there are potential risks and complications from known or unknown causes.
Possible side effects may include, but are not limited to: mild to moderate redness, peeling or flaking, dryness, tenderness, temporary irritation, breakouts, cold sores, or allergic reactions. Most side effects are temporary and typically resolve within 3–7 days.
If I am allergic to any ingredients used during the treatment, I understand there is a risk of an allergic reaction.
I have disclosed all relevant health and skincare information to the best of my knowledge and understand that withholding information may increase my risk of adverse reactions.

Pre- and Post-Treatment Care:

I understand it is recommended to avoid Retin-A or similar products for 72 hours, Accutane for 6 months, and waxing for 24 hours prior to treatment.
Following treatment, I agree to avoid Retin-A type products, aggressive exfoliation, waxing, and products containing acids not included in my recommended homecare regimen for 2–4 weeks.
I acknowledge the importance of wearing a broad-spectrum sunscreen (SPF 30 or higher) daily and avoiding direct sun exposure to minimize the risk of sunburn, skin damage, and hyperpigmentation.
I understand this treatment is a strictly elective, cosmetic procedure and that no medical claims have been made or implied.

I consent to receive treatment(s) and agree to inform my skincare professional immediately if I experience any complications or concerns.

By signing this form, I release Skin By Mal and its staff from any liability for injuries, adverse reactions, or conditions resulting from skincare procedures or products used during or after my treatment.

Signature*

SKIN HISTORY

MEDICAL HISTORY

AVAILABILITY

CLIENT CONSENT & ACKNOWLEDGEMENT