Facial Intake Form

FACIAL INTAKE FORM

Name

First NameLast Name

Phone Number

Area CodePhone Number

Date

Are you under 18?

Do you have any allergies? If so, please list them below.

How long ago was your last facial?

Are you currently

Do you use any of the following?

Have you had any recent facial surgeries?

Have you had any of the following services within the last 3 months?

Have you had any of the following services within the last 2 weeks?

Do you have any metal implants or a pace maker? High frequency is sometimes used and this is a contraindication.

Do you have any special skin problems or concerns pertaining to your skin?

What are your Skin Concerns?

Please select any that currently apply to you. These are contraindications for the oxygen RX facial. If any currently apply a different facial will be performed.

An LED light face shield is used at the end of all facial treatments to treat your skin for aging, acne, pigmentation, irritated skin and/or collagen/elasticity boost. Please check any contraindications you may have to the LED. Select “prefer not to have” if you do not want the LED done at the end.

Before and after photos are taken both for personal and advertising use. I am okay with my photos being shared on social media. (If you mark no, these photos will be confidential and only yourself and SKIN by Carli will see these photos)

By signing below I acknowledge that all of the above information I have given is accurate.

Signature