MODEL INQUIRY AND INTAKE

MODEL INQUIRY & INTAKE FORM
Thank you for your interest in being a model for Alana’s Advanced Training at Moeur Wellness.

As Alana transitions into her role at Moeur Wellness & prepares to begin seeing clients this September, we are offering a limited number of model appointments at a special rate of $100 for a New Client Consultation and Treatment

While Alana brings prior experience and a strong foundation in esthetics, these training days are designed to refine her techniques within the Moeur Wellness methodology, artistry, and elevated standard of care.

This is a unique opportunity to experience The Customized 60 Facial Treatment while supporting Alana. We are incredibly grateful for your interest and support during this exciting season of growth.

Please complete the form below to be considered for an upcoming model appointment,We look forward to welcoming you into the treatment room!
Client Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How did you hear about Moeur Wellness? (Instagram, Tik Tok, Family, Friend, etc. Please state the name of who referred you)
Please upload photos of your skin (center, left/right cheek, and left/ right jaw)

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Please take a moment to answer the following questions

What are your current skin concerns?

Rows	Please select
Hydration
Acne
Aging
Texture
PIH/ PIE
Pore Size
Scarring
Sunburn
Elasticity
Sun Damage/ Melasma

What skin care products do you currently use? (please list brands if possible)

Rows	AM	PM	Weekly
Cleanser
Toner
Serum
Moisturizer
Sunscreen
Exfoliator
Masks
Spot Treatment

Please list any other skincare goals or concerns that you may have.
Do you wear sunscreen every single day?
What services are you interested in receiving after our initial consultation?
Are you okay with photos/videos being posted of your service?
What inspired you to seek professional skincare treatments at this time?

Other
What is your goal in working with an Esthetician?
Are you open to adjusting your skincare routine if it will improve your results?
Are you wanting Moeur Wellness to customize a treatment plan designed to achieve your goals?

Please select all dates and times youre available to come in:

Rows	MORNING	AFTERNOON	EVENING
Tues, Aug 4
Sat, Aug 8
Thurs, Aug 13
Sat, Aug 15

Medical History and Consent Form:
Do you see a dermatologist?
Have you used Retin-A, Renova, Adapa-lene, Accutane, Differen, or acids (AHAs or BHAs), or Dermatologist prescribed topicals within the last week? Please specify
Have you received Botox/ Filler in the last 2 weeks
Do you have any allergies to cosmetics, food, or drug?
Have you ever had an adverse reaction from a product or treatment on your face? (If yes, please elaborate on how and where it presented in the skin)
Are you pregnant, nursing, or trying to conceive?
Do you use birth control pills, shot, or IUD? If so, which kind and how long?
Please check if you are affected by or have any of the following
For those who have an active lifestyle, please share what workouts you do along with if you take electrolytes, protein shakes, protein bars, or any supplements?
Please list any medications, vitamins, or supplements you take:
POLICIES

By agreeing to our policies, you understand that this appointment at Moeur Wellness is reserved exclusively for you and requires a 48 hour notice for cancellation or rescheduling. Canceled or rescheduled appointments within 48 hours will incur a 50% cancellation fee and No-shows will be charged 100% of the service price.
By submitting this form, you acknowledge and agree that this document serves as proof of your consent and participation. Any attempt to dispute the transaction will be met with this evidence, confirming that you have willingly filled out and agreed to the terms stated.
Client Signature
Date

MonthDayYear
Date
Should be Empty:

MODEL INQUIRY & INTAKE FORM

POLICIES