• Phases Esthetics Facial Intake & Consent

  • Welcome to Phases Esthetics. This brief intake helps us personalize today’s facial, and some enhancements may require additional screening.

  • Format: (000) 000-0000.
  • Have you received a facial at Phases Esthetics before?*
  • Which facial are you receiving today?*
  • Would you like to request an enhancement today?*
  • Enhancement choices*

  • Enzyme Enhancement Safety Review

  • These questions help us determine whether an enzyme enhancement is appropriate today. We always err on the side of caution to protect your skin.
  • Have you used retinol, retinal, prescription retinoids, exfoliating acids, benzoyl peroxide, or other strong exfoliating products within the last 5 days?*
  • Do you currently have sunburn, broken skin, an open lesion, an active cold sore, an active infection, or a significant rash in the treatment area?*
  • Have you waxed, shaved closely, dermaplaned, used a depilatory, or had another exfoliating treatment on the area within the last 7 days?*
  • Are you currently taking Accutane (isotretinoin), or have you taken it within the last 12 months?*
  • Have you had a professional peel, laser treatment, IPL, microneedling, or other resurfacing treatment within the last 14 days?*

  • Today's Skin & Health

  • Has anything changed with your health or medications since your last facial?*
  • Are you currently pregnant or breastfeeding?*
  • Are you currently using any prescription skincare products, including Accutane (isotretinoin)?*
  • Have you used any of the following within the last 7 days?*
  • Do you have any ingredient allergies we should know about?*
  • Do you currently have any of the following?*
  • What would you most like to improve today?*

  • Review & Consent

  • Photography consent*

  • By typing my full legal name below, I acknowledge that this constitutes my electronic signature and that I have read and agree to the information above.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • I certify that the information I have provided is complete and accurate to the best of my knowledge.

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