2025 Facial Intake Form

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Name* This field is required.
First Name
Last Name
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
5
Date of Birth
Date
Month
Day
Year
6
How did you hear about Suemi Beauty?Instagram or Friend/Family
7
List any medications, supplements, or herbal remedies you currently take:If none, please input N/A
8
Please list allergies or sensitivities:If none, please input N/A.
9
Preferred Massage Pressure?Hard, Medium, Soft
10
What are your specific concerns at this time regarding your skin or body?I.e. Wrinkles, Hyperpigmentation, Blemishes, etc.
11
What is your stress level right now?
Low
Average
Somewhat Stressed
Very Stressed
12
Have you ever received professional skin care treatments?
Please Select
Please Select
Yes
No
13
What is your skin type?
Normal
Oily
Acne
Dry
Aging
Combination
Sensitive
Rosacea
14
Which of the following best describes your skin typeThe Fitzpatrick skin type scale is a system of classifying human skin based on its response to UV radiation, developed by Thomas B. Fitzpatrick.
Type I - Pale white skin, blue/green eyes, blond/red hair - Always burns and never tans
Type II - Fair skin, blue eyes - Burns easily, tans poorly
Type III - Darker white skin - Tans after an initial burn
Type IV - Light brown skin - Burns minimally, tans easily
Type V - Brown skin - Rarely burns, tans darkly easily
Type VI - Dark brown or black skin - Never burns , always tans darkly
15
What skin care products do you currently use?
Cleanser
Exfoliation (Chemical or Physical)
Toner
Serums (vitamin c, niacinamide, Hyaluronic, etc.)
Moisturizer
Sunscreen
Retinol / Retin-A
All of the above
None
Other
16
What is your skin goal ?
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Have you experienced any of these health conditions in the past or present* This field is required.
Diabetes
Arthritis
Migraines
High Blood Pressure
Asthma
Seizures
Epilepsy
Depression / Anxiety
Auto-Immune Disorders
Heart Problem
Lupus
Hepatitis
N/A
Other
18
Do you grant permission for photos and videos to be taken during our session?
YESNO
19
SignaturePost Facial Care: Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results. By signing, you agree to have read the post facial care.
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Signature* This field is required.I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Melanie Yamanoha from liability and assume full responsibility thereof.
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Payment

Accepting Zelle or Venmo only

Zelle: (626) 643-2012

Venmo: @melanieyamanoha
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Location:

3447 Phoebe Court West Covina, CA 91792.

(please text when you arrive)
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