Corrective Skincare Intake Form
Share your current skincare routine, confirm any recent product use, and upload natural-light front and side photos.
Full Name
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First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What skincare products are you currently using? Please list all cleansers, serums, moisturizers, sunscreens, and any other products.
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The following products can make your skin thin and more sensitive. Are currently using any products that contain:*
Accutane (Acne medication)
Adapalene (Acne medication)
Alpha Hydroxy Acids (Glycolic, Lactic)
Alustra (Retin A)
Any acid based products
Avage (Acne medication)
Avita (Retin A)
Azelex (Peeling agent)
Clindamycin
Differin (Acne medication)
Doxycycline
Erythromycin
Exfoliants
Isotretinoin (like Accutane)
Madifloxicine
Metronidazole
Oral Antibiotics
Prednisone
Renova (Retin A)
Retin A (Acne and Anti-aging medication)
Retinol
Salicylic Acids
Tazarac (Acne medication)
Tazarotene (Tazorac)
Tetracycline
Topical Antibiotics
Tretinoin (Retin A)
I confirm that I have NOT used AHA, BHA, retinol, or similar active products for at least one week prior to my appointment.
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Yes, I confirm
No, I have used these products recently
Upload a clear photo of your face in natural lighting (front view)
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Upload a File
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Choose a file
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Upload a clear photo of your face in natural lighting (side view)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
What are your current concerns?
What are your skin care goals?
Esthetic skin care is not an exact science. Each individual’s medical history, lifestyle and skin behaves differently, therefore there's no way to guarantee a specified result or guarantee freedom from adverse side effects. Femme Lab Esthetics will take all possible precautions to avoid such complications. It is therefore imperative that you disclose all of your information candidly so that your treatment can be altered to help avoid complications. Adverse side effects of facials and waxing include but are not limited to: swelling of the face, redness of the treated area, blistering of the skin, crusting of the skin, scars, infection, cuts and burns, change of pigmentation of the skin, and allergic reaction to the products used. I have had the opportunity to ask my esthetician any questions I may have. I understand this is a cosmetic procedure with risks and potential side effects, and I voluntarily wish to have the services provided with knowledge of the potential side effects. I understand that any false information I have provided may lead to undesirable consequences and affirm I have truthfully discussed my personal and medical history to my esthetician. I further understand my failure to follow post care instructions may also lead to undesired results, complications or effects. I understand that the esthetician does not diagnose illness, disease, or any other physical or mental conditions. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against Femme Lab Esthetics and its service providers. I have read the above information and if I had any concerns, I have addressed them with my esthetician. I give permission to my esthetician to perform the procedure we have discussed and will hold them harmless from any liability that may result from this treatment. I have given an accurate account of all known allergies or prescription drugs and products I am currently ingesting or using topically. This waiver will be kept on file and will apply to each and every service I receive today and in the future. By signing this document state that I have read, agree and understand the terms herein and voluntarily have accepted the service and any potential risks that may be associated with the service.
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