Piel de Miel Facial Intake Form

Date

Today's Date

Name

First NameLast Name

Address

Street Address

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Date of Birth

What facial did you book?

Please be advised that if booking the nano-needling facial, you may not be a suitable candidate if you are experiencing any of the following:

Active acne or open lesions

Compromised skin barrier: Eczema flare, psoriasis flare, dermatitis

Recent filler, Botox, or injectables

If you require any assistance on which facial to book, please reach out to me via DM or text message!☺️

Do you consent to being photographed and recorded during your appointment? (Please be advised that any content may be shared on social media platforms or for promotional purposes).

Would you like a silent appointment? We all have those moments where we prefer silence.

Please indicate which services you are interested in:

What do you wish to work on with your skin?

If possible please upload photos of your areas of concern (not required)

Are you currently or have you previously experienced any of the following?

Please list allergies or sensitivities (Please note if you are allergic to aspirin as salicylic acid contains aspirin) :

Please list all over the counter and prescription medications you are currently taking?

Please indicate if you have ever used any of the following for skin treatment:

What condition were you treating with this medication? When was the last time you used these medications?

Are you pregnant?

Are you planning a pregnancy in the near future?

What skin care products are you currently using?

Are you wearing a daily sunscreen?

If yes, what type and SPF:

Is your skin:

Have you ever been treated for a skin condition? If yes, what condition?

How did you treat the condition?

Were you happy with the results:

Are you currently being treated for any skin conditions?

Do you come in contact with any chemical at work?

Do you work around excessive heat or cold?

Do you use Personal Protective Equipment (PPE)? If so what type and for how long? (ex: gloves, masks,shields,etc)

How often do you exercise?

Average hours of sleep?

What is your stress level (i.e. low, moderate, high)

How many hours a day are you exposed to sunlight?

Please indicate any of the following that apply to your eating habits"

How much water do you drink per day?

How much caffeine?

Carbonated drinks?

Average alcohol consumption per week?

Do you smoke tobacco products?

Have you changed your brand of skin care products in the last year? If yes, why did you change?

By submitting this facial consent form, you agree to the following:
1) I give my permission to receive facial services.
2) I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications.
3) I understand the importance of informing my esthetician of all medical conditions and medications I am taking, and to let the esthetician know about any changes to these. I understand that there may be additional risks based on my physical condition.
4) I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust accordingly.
5) I understand that I or the esthetician may terminate the session at any time.
6) I have been given a chance to ask questions about the session, and my questions have been answered.

7) I understand the risks associated with facials and waxing include, but are not limited to:

Redness or irritation
Superficial bruising or redness
Lifted or torn skin I, therefore, release Piel de Miel and the individual esthetician from all liability concerning these injuries that may occur during the facial session.

Signature

Things to Know

Interest

Medical History

Women

Skin Self- Analysis

Lifestyle and Stress Analysis