Facial Intake Form

FACIAL INTAKE FORM

Name*

First NameLast Name

Phone Number

Area CodePhone Number

Date

Are you under 18?*

YesNo

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*