Skincare Intake Form

Date

Name

First NameLast Name

Have you had a facial before?

Does your face get reactive? Do you turn red or breakout after using a product? How does your skin react to heat?

What types of products do you use for your skin? What is your skin routine like?

What type of skin do you think you have? (Please list all that apply)

How would you rate your skin type on the Fitzpatrick Scale? (Please pick one)

Do you currently use any form of Vitamin A / Retinol or acne medications? Or have you been on Accutane? If so, please list the date as well.

If you've recently had a facial wax, please list the date here.

Have you recieved Botox or fillers in the last two weeks?

Are you interested in product recommendations / purchasing retail?

I understand that skincare treatments, including but not limited to facials, exfoliation, chemical peels, extractions, high-frequency, LED light therapy, microcurrent, hydrodermabrasion, masks, and other professional skincare treatments, may cause temporary or unexpected reactions.

Possible reactions may include, but are not limited to, redness, irritation, dryness, sensitivity, swelling, itching, breakouts, bruising, peeling, burning, allergic reaction, increased sun sensitivity, hyperpigmentation or hypopigmentation, and, in rare cases, injury or scarring.

I agree to provide complete and accurate information regarding my health history, medications, allergies, skin conditions, pregnancy status, recent procedures, products I use, and any other information that may affect the safety or outcome of my treatment. I understand that failure to disclose relevant information may increase my risk of an adverse reaction.

I understand that individual results vary and that no specific result or outcome can be guaranteed.

I agree to follow all pre-treatment and post-treatment instructions provided to me. I understand that Sea Breeze Beauty is not responsible for reactions or complications resulting from my failure to disclose relevant information, follow aftercare instructions, use products contrary to professional recommendations, or engage in activities that may negatively affect my skin following treatment.

I understand that I have the opportunity to ask questions about my treatment and that I may decline or discontinue a treatment at any time.

By signing below, I acknowledge that I have read and understand this consent and waiver, have disclosed all relevant information to the best of my knowledge, and voluntarily consent to receive skincare treatments from Sea Breeze Beauty.