Facial Questionnaire
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Please select what you believe your skin type is like. You may select more than one option.
Oily
Normal
Dry
Acne prone
Sensitive
Hyperpigmented
Do you use any acne medication products orally or superficially such as
Retin-A
Renova
Adapalene
Retinol
Acutane
Other
Have you had any manual/machine facials, waxing, or electrolysis done in the past 2 weeks?
Yes
No
Have you had any chemical peels or lasers?
Yes
No
Are you sensitive to heat/steam? Do you turn red or get hives from heat exposure/steam?
Yes
No
Do you often experience breakouts?
Yes
No
Do you often get/have blackheads?
Yes
No
Are you using any products that have the following ingredients?
Glycolic Acid
Salicylic Acid
Exfoliating scrubs
What skin care products are you using? What do you wash your face with?
What are your skin goals? What do you wish to get out of this facial?
The facial includes a 15 minute European facial massage. How do you prefer the pressure?
Soft
Moderate
Strong
Other
What is your purpose for this facial? You may select more than one option.
Relaxation purposes
Cleansing/exfoliation purposes
Extraction purposes
Maintenance
Before or after the facial, your Esthetician will suggest a home-care skin routine. Purchasing is not mandatory. We do not sell skin care products on sight, however, we will make recommendations according to your skin type and needs. For best results, it is highly recommended that you keep a good home skin routine and come once a month for "maintenance". By initialing below you are agreeing that you have read and understood.
Please be advised that the facial might be recorded for advertising purposes. If you do not wish to be recorded, please advise your esthetician. By initialing below you are agreeing to possibly being recorded.
Added Services
Please choose the added services that interest you
MICRODERMABRASION ($50) - a non-invasive procedure that's for exfoliating surfaces to help remove the superficial layer of dead skin cells. It then quickly replaces the lost skin cells with new, healthy ones.
MANUAL EXTRACTIONS, with Scaling solution ($10) - solution loosens the sebum (oil) and assists with extractions. This will be followed by a pH balance solution to balance the pH of the skin.
CHEMICAL PEEL ($50-$100)
Consent for treatment
It is my choice to receive treatments. I agree to communicate with my service provider any time I feel as though my well-being is being compromised. I understand that the service providers do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, or pharmaceuticals. I acknowledge that the performed services are not a substitute for medical examination or diagnosis. I understand that there are no guarantees when receiving facial treatments. I have stated all medical conditions that I am aware of, and will update the service provider of any changes in my health status. I understand that Vera, the provider, is a licensed professional, and that by law has the right to refuse service on any client at any time, if they feel as though their well-being is compromised. By signing below I also release BellaBrow by Vera Esthetics LLC of any and all liability.
Please sign below for your consent
SUBMIT
Should be Empty: