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Please carefully fill out the following form prior to your beauty treatment. 

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
General Health Information
Are you currently pregnant?*
No
Yes
Are you currently breastfeeding?*
No
Yes
Medical conditions (please select all that apply) *
Allergies
Diabetes
High Blood Pressure
Low Blood Pressure
Epilepsy
Heart Disease
Metal Implants
HIV
Hepatatis
None
Are you currently taking one of the following medications?*
Allergies
Antidepressants
Retinoids
Antibiotics
None of the above
Skin Assesment
How would you describe your skin?*
How would describe the level of your skin hydration?
Well-hydrated
Somewhat hydrated
Dehydrated
Please select all skin conditions which apply to you*
Rosacea
Acne
Hyperpigmentation
Moles / Naveus
Milia
Pustules
Dark spots
Skin Tags
Blackheads
Signs of aging (fine lines, wrinkles)
None of the above
Which skin concern is your priority?*
Acne
Hyperpigmentation
Skin sensitivity
Signs of aging
Sun damage
Dark circles
Dehydration
Other
Which skin treatment(s) would you be interested in?*
Deep Cleansing Facial
Microneedling
Chemical Peel
Microdermabrasion
Dermaplaning
BB Glow Facial
Ultrasonic Facial
Hydrating Facial
LED Light Therapy
Exfoliation
Anti-aging Facial
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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