Teen Facial Intake Form

Minor Full Name

First NameLast Name

Parent Full Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Goals for this session?

Please list allergies or sensitivities (Please note if you are allergic to aspirin as salicylic acid contains aspirin) :

Anything else I should be aware of or you want me to know?

Minors are permitted to receive treatment at Piel de Miel LA. A parent or legal guardian must be present to complete the Intake Form for the minor.

Minors (guests between the ages of 13 and 17) can receive facials only with written consent from a parent or guardian.

The consenting adult, child, and technician will establish goals for the treatment session.

For guests ages 13-17, the parent or guardian must be present in the treatment room during the entire service.

Signature