Facial Intake Form

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

How often do you receive facials? When was your last facial?

What prevents you from receiving regular facials?

What would you like to achieve from todays session? What are your longterm skin goals?

What are your main skin concerns?

Have you had facials treatments before? If yes, when?

Have you ever had... Mark all that applies

Do you use any form of Retinol, AHA (Lactic, Glycolic, Mandelic Acid) or BHA(Salicylic Acid)?How often? Are you on any acne medication?

What is your current skincare regime?

Any hair removal on face or neck in the past 4 weeks?

What concerns do you have with your skin?

Do you burn easily in moderate sunlight?

Do you every experience burning, itching or stinging sensations on your skin?

Do you have any allergies? Are you allergic to any products or ingredients? If yes, please list them.

Are you currently taking any medications? If yes, please specify.

Do you have any of the following medical conditions?

Do you have any metal implants, a pacemaker, or body piercing?

Have you had any surgery within the last six months?

Do you give consent for photos/ videos to be taken during your service and be used for promotional purpose?

Are you pregnant or trying to become pregnant?

What is your current skincare routine? (Please list products and frequency)

What are your goals for today's facial treatment?

eg. Focus on extraction, recommend products, relaxation

I,the undersigned Guest. understand that skin therapy is not a substitute for medical examination or diagnosis, and that I should see a physician for any ailment or medical condition. I acknowledge that it is my responsibility to inform the therapist prior to the treatment of any medical conditions or any questions or concerns that I may have. I understand that my participation in the treatment carries inherent risks that cannot be eliminated regardless of the care taken to avoid injury. I assume all risks and accept full responsibility for the receipt of treatment.I am aware that draping will be used during the session. I understand that the Session is not sexual in any manner and that any sexually suggestive remarks or advances made by me will result in immediate termination of the Session. I understand that if at any time I have concerns about the Session or experience any discomfort, I am to bring the issue to the Therapist's attention. I may terminate the Session at any time. If at any time there are changes to the information given, or in my condition, I will notify my therapist, and update this form before receiving additional services.

CONSENT TO SKINCARE TREATMENT FOR MINOR

It is Skin Studio by Parveens practice to offer the safest and most conservative approach to delivering therapeutic services to guests, including minors (under 18 years old) who require additional contractual and safety precautions.

Skincare Minor Policy

All Minors (guests 11-18 years old)

*Guest must be atleast 11 years old to receive Skincare services

* Minors must have a parent or gurdian sign the consent to Treatment of Minor section to recieve services

*Guests under the age of 18 cannot recieve any peels, or dermaplaning

*Minors under age of 16 years old must have a parent or gurdian in the room.

By my signature below, I hereby acknowledge that I fully understand the expectation and limitations of my child or dependent recieving a Minor Facial and authorize the therapist to administer Skincarre Therapy techniques to my child or dependent as they deem necessary.

Age of Minor

Parent/ Guardian Name

Date

Parent/Guardian Signature

PEEL CONSENT FORM

The exfoliating peel treatment included in your facial service is designed to resurface the skin. During the service, you may experience some temporary discomfort, redness, sensation of tingling, itching, or stinging. Please inform your professional skin therapist if you experience these sensations.

I understand that I cannot have this peel service if any of the following apply:

• Recieved a cosmetic light-based procedure such as laser treatment, IPL, etc. within the last 6 weeks.

• Facial waxing within the last 72 hours (about 3 days).

• Active herpes, cold sores, fever blisters or open lesions.

• Use of Isotretinoin (Accutane) in the last 6 months.

• Use of Retin A or Renova in the last 2 weeks.

• Received Botox or other injectable procedure within the past 7 days.

• Pregnant or lactating.

• Recently sunburned/windburned in the last week.

I acknowledge that no specific guarantees can be or have been made concerning the expected results of the Service. I have been advised of and acknowledge the importance of applying sunscreen as instructed. I will not pick, peel, or use an abrasive product on the treated skin area for several days following the Service. I understand that I should avoid direct sun exposure and/or tanning booths immediately following the Service and that I must protect my skin with sunscreen SPF 30 or above and UVA, and UVB protection.

I will consult with my Skincare Therapist with any questions or concerns regarding the Service or home care instructions/products.

I certify that I have read and fully understand this Consent Form. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.

Guest Name

Guest Date

Signature