Moonlit by Maggs Intake Form

Moonlit by Maggs Intake Form ♡

Please fill this form out prior to your appointment.
Name

First NameLast Name

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

Email
example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any sinus problems?

Please list any/all allergies. Ex: food or cosmetic products, botanical or herbal ingredients

Do you have any metal or electrical implants?

Have you undergone surgery recently?

Please list any medications or vitamins you are currently using.

Are you currently using/have you recently used:

What is the main goal of your ritual today? Ex: natural pick me up, special event, education on your skin, etc.

What are the issues/areas you are mainly focused on for your appointment? Ex: texture, chin, dehydration, fine lines around the mouth

Do you ever experience skin breakouts?

Do you have tendency of redness?

Do you easily sunburn?

Do you wear SPF? (Honestly is the best way for me to treat you!)

Have you experienced any of the following in the last two weeks?

Please give a detailed list of your skincare routine products. Ex: Cera Ve foaming cleanser, Byoma hydrating toner, Aveeno oat moisturizer

What is your water intake?

What does your diet consist of?

What are your stress levels lately?

How many hours of sleep do you average per night?

Do you smoke/vape or drink regularly?

Are you trying to become pregnant?

Are you due for your period in the next week?

What is your pain threshold? (Extractions)

What is your massage preference?

I confirm that the information I have provided is accurate & complete. I agree to inform my Esthetician of any changes in my health, medications, or skincare routine. I understand treatments may cause temporary reactions like redness or sensitivity. I consent to treatment and acknowledge results are not guaranteed. I understand photos may be used for progress tracking and/or marketing with my consent.

*Signature after Next*

Signature
Should be Empty: