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Mindful Facial Intake Form

Once you arrive for your facial appointment Andi will ask you questions regarding your skin and health history.

I agree that I will answer all of the skincare questions to the best of my ability and honestly. I am responsible for letting Andi know if any of these things change or my health history changes.

I acknowledge that I must adhere to Mindful Practice LLC’s policies. I understand that any amount of tardiness will result in myappointment being shortened for the sake of the practitioner’s scheduled clients. 

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. 

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 1 weekfollowing treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Mindful Practice LLC and its affiliate Salon, Lovdahl Salon & Studio of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

First Clients Name

First Name*

Middle Name

Last Name*

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

Email*

Confirm Email*
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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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