Facial Intake Form

Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Today’s Date *

MonthDayYear
Birth Date

MonthDayYear
How did you hear about us?*
The information you provide allows us to tailor your treatment safely and effectively. Please complete this form honestly and as accurately as possible to ensure the best results.
What do you consider your skin type? (Select all that apply, to the best of your ability):*

NormalOilyAcne-proneDryAgingCombination (Dry and Oily areas)SensitiveRosacea
Which skin concern(s) would you like to primarily focus on? (Skip if you just want to unwind!)

Pigmentation/Uneven ToneLines and WrinklesActive AcneDehydration or TightnessAging or Sagging SkinDullnessDark CirclesSensitivity or RednessRosaceaPuffinessExcess OilTexture ConcernsEnlarged PoresCongestion in T-ZoneOther
For your safety, please indicate all that apply to you:*

Pregnant or tryingLess than 6 weeks PostpartumBreastfeedingHigh Blood PressureBruise EasilyPoor Wound HealingSeizuresUsed Retin-A (or a similar medication) within the past 10 daysCurrently on my menstrual cycle OR will start within 2 daysBleeding DisorderActive Cold SoresDiabetic or diagnosed with a different autoimmune diseasePacemaker or Metal/Electronic ImplantsNone of the aboveOther
If relevant, please describe any of the above information checked off:
Medication taken within the last 6 months*

AccutaneIsotretinoinRetin-A or other retinoidsAdapaleneDifferin GelBlood ThinnersVitamin A/C/ENoneOther
Recent procedures on face, neck and/or décolleté area*

PeelsLaserIPLDermaplaneMicroneedlingInjectables (e.g., Botox, filler)WaxingMicrobladingTanningNoneOther
Please list any medications, supplements, or herbal remedies you currently take:
If none, simply write “none.”
Please list the skincare products you currently use at home.*
Including cleanser, toner, serum/treatments, moisturizer, sunscreen, exfoliants (physical or chemical), and any other skincare products or tools. To better customize your treatment, please be as specific as possible. List the brand + product name (for example: CeraVe Hydrating Cleanser).
Please list any known allergies, sensitivities, or adverse reactions you have experienced*
(e.g., skincare ingredients, latex, fragrances, medications) If none, simply write “none.”
If necessary, would you like extractions performed?
Extractions can cause discomfort, and exfoliants may cause a slight tingling sensation. Both are important for clearing congestion and achieving the best results. The rest of your facial will remain relaxing and soothing.
Requesting Accommodations or Modifications
If you experience chronic pain (e.g., back, shoulders, neck) or have any other physical needs or limitations, please let us know how we can best support your comfort during your service.
Is there anything else you’d like to share so I can give you the best experience possible? Any special occasions or celebrations coming up this week?
Before Your Appointment

For optimal results, try to arrive makeup-free, avoid retinoids or exfoliants 3–5 days prior, limit heat and sun exposure 2 days before and after, and drink plenty of water.
By submitting this form, you agree to the following:
1. I give permission to receive facial, light massage, brow/lash lamination, and/or waxing services.
2. I understand that the esthetician does not diagnose illnesses or injuries, prescribe medications, or provide medical advice.
3. I have clearance from my physician to receive facial, massage, and waxing services.
4. I understand that the risks associated with massage, facials, and waxing include, but are not limited to:
  • Superficial bruising or redness
  • Short-term muscle soreness
  • Exacerbation of undiscovered injury
5. I release Cindy Perez from all liability concerning any injuries that may occur during this session.
6. I understand the importance of informing my esthetician of all medical conditions, medications, and any changes to these. I acknowledge that additional risks may exist based on my health.
7. I understand it is my responsibility to inform my esthetician of any discomfort during the session so adjustments can be made.
8. I understand that either I or the esthetician may terminate the session at any time.
9. I have been given the opportunity to ask questions about the session, and all my questions have been answered to my satisfaction.
Signature*
Should be Empty:

The information you provide allows us to tailor your treatment safely and effectively. Please complete this form honestly and as accurately as possible to ensure the best results.

Before Your Appointment