Intake Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Date

How did you hear about us?

List any medications, supplements, or herbal remedies you currently take:

Please list allergies or sensitivities:

What are your specific concerns at this time regarding your skin?

What is your stress level right now?

Primary Skin Concerns

Are you currently using Retin-A, Tretinoin, or Accutane?

Have you received Botox or Filler in the last 4 weeks?

What is your current ritual?

What is your goal for this session.

Signature

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive these facials.
2) I understand that therapeutic massage is not a substitute for traditional medical
treatment or medications.
3) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.
4) I have clearance from my esthetician to receive facials.

I, therefore, release Moonlux Skin & Wellness and the esthetician from all liability concerning these injuries that may occur during the massage session.
6) I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
7) I understand that it is my responsibility to inform my esthetician of any
discomfort I may feel during the session so she may adjust
accordingly.
8) I understand that I or the esthetician may terminate the session at any
time.
9) I have been given a chance to ask questions about the session
and my questions have been answered.