Mindful Glow Custom Facial

Mindful Glow Custom Facial

Client Intake Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
DOB

MonthDayYear
Date
Emergency Contact & Phone Number
Health History & Safety Questions: Please check all that apply or have occurred in the past 6 months.

Pregnancy (or trying) or NursingDiabetesHigh blood pressureLow blood PressureHeart Condition or PacemakerSeizures or EpilepsyCold sores/HerpesClaustrophobiaRecent surgery or Cosmetic proceduresAllergies to nuts, Essential oils or BotanicalsSkin Conditions ( eczema, psoriasis, rosacea, etc.)Use of Accutane or Retin- A or Vtamin A products in the last 6 months?Recent sunburn or tanning bed exposureActive acne or open lesionsDo you have eyelash extensions?Have you received Botox or filler injections in the last 2 weeks?
Are you being treated for any conditions by a physician or dermatologist?
Are you currently taking any medications?
Have you had any facial or dermatology services in the last 14 days? (waxing, laser treatments, chemical peels etc.) If so, please explain.
Do you have any allergies or sensitivities? If so, please explain.
Skin Profile: What are your current skin concerns or goals?

Dryness or dehydrationOily or congested skinBreakouts or acneUneven skin tone or dark spotsFine line or wrinklesRedness or sensitivityDullness or texture
Any other concerns you would like to address regarding your skin?
Your skin type:

NormalDryOilyCombinationSensitive
To learn more about your skin and how it reacts, let me know about your skincare routine in the following section. If you do not use any particular product or tool in a section, leave it blank.
What cleanser or process do you use to cleanse your face?
Do you exfoliate, and if so how?
Do you use a toner?
What serums are you currently using?
What moisturizer are you currently using?
Do you apply sunscreen?
Many of the products we will be using in your service will contain essential oils and botanicals. The information below will help me to make your service safe and enjoyable to you.
CONTRAINDICATIONS: Some of these are repeated from above health history. They are important to know when working with essential oils. Check all that apply.

EPILEPTICELDERLYCHILDESTROGEN-RELATED CANCER HISTORYBLEEDING DISORDERENDOMETRIOSISPARKINSONSALLERGY OT CEDARLOW BLOOD PRESSUREBLOOD THINNER MEDICATIONSASTHMATICHIGH BLOOD PRESSUREHOMEOPATHIC REMEDIESPOOR KIDNEY FUNCTIONANTIDEPRESSANT MEDICATIONCARDIAC FIBRILLATIONRAGWEED ALLERGYSKIN SENSITIVE
Do you have known allergies or sensitivities to essential oils or botanicals?

YesNo
If "Yes" please explain.
Preferred scent profiles (choose any you enjoy):

Floral (rose, lavender)Herbal (rosemary, tea tree, basil)Woodsy (cedarwood, sandlewood)Citrus (orange, lemon, bergamot)Earthy(patchouli, frankincense)Minty ( peppermint, spearmint)
Any scents you dislike or want to avoid?
Consent & Agreement

There is always a potential risk to having product applied to skin, rare, but always there. I have answered these questions to the best of my knowledge so that my practitioner can lower my risks of an unpleasant outcome.

I realize that skincare is a journey. I do not expect lasting results without follow up treatment at home and maintenance treatments by a professional practitioner. I do however look forward to my relaxation during this service and my first step to my natural skincare routine!

I understand it is important to follow any instructions for post treatment care.

I understand that this is a non-invasive skincare and aromatherpay treatment. My practioner is NOT a physician and IS a Licenced Cosmetologist and Certified Aromatherapist, and will only work under that scope of practice. I have disclosed any conditions that may affect my service. I release the practioner from liabilty and acknowledge that results may vary.
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