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FACIAL INTAKE FORM


By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform the Esthetician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the business for any injury or damages incurred due to any misrepresentation of my health history. 

Today's Date: December 30, 2024

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

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

Esthetics Information

What type of skin do you have?*
What areas of concern do you have regarding your skin? *
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness/Rudiness
Dehydrated
Sun, Liver, Brown Spots
Other

If Other, please explain
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Other

If Other, please explain
Do you currently or have you used in the last 3 months Retina-A, AHA's or Retinol/Vitamin A derivative products?*
No
Yes

If yes, please describe
Have you received Botox, Restylane, or Collagen injections in the last 6 months?*
No
Yes

If yes, please specify
First Client's Signature*
UPGRADES: 24K Eye Mask, Peptide recovery mask, LED light therapy upgrades:
For Deluxe facial only: 24K gold eye mask. $20 upgrade *
No
Yes
Ultimate Peptide Recovery Mask with 15 minute red LED light treatment. $50 upgrade *
No
Yes
LED red light therapy 15 minute session $30 *
No
Yes
Parent or Guardian's Email Address

Email*

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

Emergency Contact *

Relationship *

Phone *
How did you hear about us?

How did you hear about us? *
Do you have a gift card or certificate?
Do you have a gift certificate or card?*

How much? *
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 Information

Esthetics Information

What type of skin do you have?*
What areas of concern do you have regarding your skin? *
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness/Rudiness
Dehydrated
Sun, Liver, Brown Spots
Other

If Other, please explain
Have you been under the care of a dermatologist within the past year?*
No
Yes

If yes, please explain
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreen
Drugs
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Other

If Other, please explain
Do you currently or have you used in the last 3 months Retina-A, AHA's or Retinol/Vitamin A derivative products?*
No
Yes

If yes, please describe
Have you received Botox, Restylane, or Collagen injections in the last 6 months?*
No
Yes

If yes, please specify
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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