New Facial Intake

New Facial Intake Form

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

Date

How did you hear about Essential Esthetics by Zoey?*

...Skin Care...

Let's start here. Help me learn more about your skin, so we can get you to your goals!

What products do you use on a regular basis?*

What treatments have you received before:*

In the last 2 weeks, have you:*

Been WaxedUsed a Tanning BedNone of the above

Have you ever used or are currently using Accutane, Tretinoin Cream, Retinols (vitamin A), or Topical Antibiotics?*

YesNo

*Please note that I require 6 months from stopping Accutane and receiving facial or waxing services.

What would you like to change about your skin? (Mark all that apply)*

...General Health...

Everything affects your skin. Please answer so we can find what's right for you!

In the last year, have you:*

had surgerybeen under a physician's care for anything other than annual wellnessI have not had surgery or been under a physician's care

If you answered yes to surgery or been under a physician's care in the last year, please explain below.

example: gallbladder surgery, high blood pressure, depression, etc.

Do you have:*

Please list all medications, vitamins, supplements, etc.*

Please type none if you are not on medications.

Are you:

PregnantTrying to Become PregnantLactatingNone of the above

Please mark any allergies you have:*

Are you claustrophobic?*

YesNo

Please provide any other information you feel will help me offer you the best service.*

Please type none if there are no special instructions.

...Policies...

I have answered the above honestly and to the best of my knowledge. All of the above play a role in your chemical makeup, including your skin.

No guarantees can be made and no refunds will be given for services rendered. If, for any reason (including starting your cycle), you need to reschedule, cancel or adjust your appointment (ie, removing a service from what is scheduled or selecting a lower priced service), we kindly ask for 48 hours notice. All fees will use the card on file.

Less than 48 hours - 50% fee of scheduled service(s)
Same day up to 2 hours - 75% fee of schedule service(s)
Less than 2 hours or no call/no show - 100% fee of scheduled service(s)

Tardiness may result in modifying the service according to time remaining. Regular charges apply.

Repetitive cancellations/reschedules may prevent access to online booking.

I also understand that according to insurance and to maintain a peaceful environment, children and additional guests are not permitted under any circumstance.

I understand and agree to the policies listed above.*

I understand and agree to the policies

Date*

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.