FINAL Facial Intake Form

Name*

First NameLast Name
Today's Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Birthday

MonthDayYear
Date
How did you hear about Fresh Complexions?
List any medications, supplements, or herbal remedies you currently take:
Do you have ANY allergies? Any product sensitivities?
What brings you in today? Do you have any special skin problems or concerns?
Do you have lash extensions?

No lash extensionsYes I have extensions
Do you wear hearing aids?
Current skincare products & routine
What is your daily skin care routine? Morning and night time - and what products do you use?
Cleanser
Toner
Exfoliator

Day moisturizer/Night moisturizer

Any Serum?

Anything else you use?
Please check all that apply.*

High Blood PressureDiabetesSeizures/epilepsyPregnancyJaw Pain / Clenching/ GrindingMetal ImplantsFibromyalgiaRetin -A use within the past 10 daysHistory of any type of cancerNone of the aboveOther
Do you have hair extensions?

YesNo
Do you smoke anything or vape?

YesNo
Are you currently using any acne medication? (Topical OR injesting)

YesNo
Have you had any fillers (Botox, Juvederm, etc) or plastic surgery in the past six months?

YesNo
By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive facial treatments (including but not limited to LED treatment, high frequency, dermaplaning, facial massage, and/or waxing services.)
2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.
3) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.
4) I have clearance from my physician to receive facials.
5) I understand the risks associated with massage therapy, facials, dermaplaning and waxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Fresh Complexions llc and Rita Krause from all liability concerning any injuries that may occur during the treatment session.
6) I understand the importance of informing my aesthetician of all medical
conditions and medications I am taking, and to let them know about any changes to these. I understand that there may be additional risks based on my physical condition.
7) I understand that it is my responsibility to inform my aesthetician of any
discomfort I may feel during the session so he/she may adjust accordingly.
8) I understand that I or the aesthetician may terminate the session at any time.
9) I have been given a chance to ask questions about the session and my questions have been answered.
CANCELLATION POLICY

I appreciate your business. So that i can best serve all clients, please be advised of these policies.

*CHANGING YOUR APPOINTMENT
24 hours’ notice is required to reschedule or cancel a booked appointment, except in cases of contagious illness as described below. If 24 hours notice is not given, you will be charged a booking fee equal to the cost of the missed appointment.
SICKNESS OR FAMILY EMERGENCY If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. There is no penalty in this case. if the weather is questionable and the roads are bad, we can certainly reschedule with no penalty.
Signature*

Clear
Parents signature if client is a minor

Clear
Should be Empty:

Current skincare products & routine