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Please tell us about your skin today...

Please select who will be receiving service...
AdultMinor
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First Client's Name

First Name*

Last Name*
First Client's Date of Birth*
First Client's Information
Have you seen a doctor in the past year for a skin order?*
No
Yes

If yes, please explain.
Are you experiencing any skin problems now?*
No
Yes

If yes, please explain.

What is your objective for your facial today?

Are there specific areas or issues you'd like to focus on?
Would you like suggestions for home care products to address your concerns?*
Yes
No
Are you currently under a doctor's care?*
No
Yes

Please list any diagnosed conditions.
Are you currently taking any:
Prescriptions
Medications
Hormones
Vitamins
None of the above

If yes, please list.
Have you used or are you using (check all that apply): *
Not using anything
Accutane
Diet tablets
Diuretics
Retin-A
Laxatives
Oral contraceptives
Smoke
Stimulants
Alpha Hydroxy Acid / AHA's
Other

If "other", please explain.
Have you ever undergone cosmetic surgery or had dermabrasion?*
No
Yes

If yes, please explain.
Do you get injectables (ie Botox)?*
No
Yes

Most recent approximate date and location?
Are you pregnant?*
No
Yes
Do you consume alcohol?*
No
Yes

If yes, how many glasses per week?
Do you have any allergies to: *
None
Cosmetic ingredients
Pollen
Essential oils
Animals
Other

If "Other", please explain.
Have you ever had a reaction to any treatments?*
No
Yes

If yes, please explain.
Redness tendency?*
No
Yes
Sinus problems?*
No
Yes
Massage preference?*
Light
Firm
Please select all you use for your home care routine. *
Cleanser
Soap on face
Toner
Scrub
Masque
Peel
Moisturizer
Serum
Facial Oil
SPF
None of the Above
First Client's Signature*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Please tell us...

How did you hear about us?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 17 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you seen a doctor in the past year for a skin order?*
No
Yes

If yes, please explain.
Are you experiencing any skin problems now?*
No
Yes

If yes, please explain.

What is your objective for your facial today?

Are there specific areas or issues you'd like to focus on?
Would you like suggestions for home care products to address your concerns?*
Yes
No
Are you currently under a doctor's care?*
No
Yes

Please list any diagnosed conditions.
Are you currently taking any:
Prescriptions
Medications
Hormones
Vitamins
None of the above

If yes, please list.
Have you used or are you using (check all that apply): *
Not using anything
Accutane
Diet tablets
Diuretics
Retin-A
Laxatives
Oral contraceptives
Smoke
Stimulants
Alpha Hydroxy Acid / AHA's
Other

If "other", please explain.
Have you ever undergone cosmetic surgery or had dermabrasion?*
No
Yes

If yes, please explain.
Do you get injectables (ie Botox)?*
No
Yes

Most recent approximate date and location?
Are you pregnant?*
No
Yes
Do you consume alcohol?*
No
Yes

If yes, how many glasses per week?
Do you have any allergies to: *
None
Cosmetic ingredients
Pollen
Essential oils
Animals
Other

If "Other", please explain.
Have you ever had a reaction to any treatments?*
No
Yes

If yes, please explain.
Redness tendency?*
No
Yes
Sinus problems?*
No
Yes
Massage preference?*
Light
Firm
Please select all you use for your home care routine. *
Cleanser
Soap on face
Toner
Scrub
Masque
Peel
Moisturizer
Serum
Facial Oil
SPF
None of the Above
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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