Facial Intake Form

Name:*

Address:*

City:

State:

Zip:

Main Telephone*

DOB:

Referred by:

Emergency Contact:

Email Address:*

Please take a moment to carefully read following information and sign where indicated

Is this your first facial?*

Yes
No

Do you like steam on your face?*

Yes
No

If No, Why?

Are you expecting to have extractions done?*

Yes
No

How do you wash your face?*

Soap
Cleanser

which Brand?

Do you moisturizer?*

Yes
No

If Yes, which brand?

Do you use Glycolic acid on a regular basis?*

Yes
No

Have you or are you using Retin A?*

Yes
No

Are you / Have you taken accutane?*

Yes
No

Are you taking any medications?*

Yes
No

if Yes, please specify:

Do you ever have burning/itching on your skin?*

Yes
No

Do you have allergies to cosmetics, foods, or drugs?*

Yes
No

if Yes, please specify:

Do you consume water daily?*

Yes
No

How much?

Do you drink coffee/tea, or soda?*

Yes
No

Coffee ozs:

Tea ozs:

Soda ozs:

Do you experience redness/irritation often?*

Yes
No

Do you have heart trouble?*

Yes
No

Are you diabetic?*

Yes
No

Have you had cosmetic surgery?*

Yes
No

If Yes, please specify:

Please circle all that apply:

Please explain problems that were circled and list anything else we should be aware about:

I understand that the information herein is to aid Esthetician in giving a better service and is completely confidential and fully understand the above questions and authorize treatment.

Client's Signature: