Intake Form Consent Form "*" indicates required fields Step 1 of 10 10% What is your name?* First Last When were you born? MM slash DD slash YYYY Where do you live?* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State What is your phone number?*What is your email address?* How did you hear about us?*FacebookInstagramGoogleWord of mouthFriend or relativeWebsiteReason for booking a sevice today?*Check all that apply Relaxation / facial Micro-needling Waxing services Body treatment Permanent makeup -lip- eyebrows Tattoo removal Lashlift - lamination What is your skin condition today?*Check all that apply Oily Dry Sensitive None of the above What concerns do you have regarding your skin?*Check all that apply Breakouts/Ance Excess oil/shine Blackheads/Whiteheads Wrinkles/fine lines Redness/ruddiness Uneven skin tone Dull/dry skin Dehydrated Sun damage Rosacea Sun, liver, brown spots Do you wear contact lenses?* Yes No Do you have any metal implants?* Yes No Are you currently on antibiotics?* Yes No Are you currently using Accutane, Retin-A, Retinol, AHA's vitamin A derived products?* Yes No Are you a smoker?* Yes No Are you taking birth control?* Yes No Are you pregnant?* Yes No Are you nursing?* Yes No Are you a habitual tanner?* Yes No Do you currently have a sunburned or windburned face?* Yes No Do you consistently wear sunscreen?* Yes No Do you experience stress often?* Yes No Do you suffer from cold sores?* Yes No Do you suffer from allergies?* Yes No Do you have allergies to products or materials such as latex?* Yes No What are you allergic to?* Have you been under the care of a detratologist within the last year?* Yes No Do you have collagen, botox, or other dermal filler injections?* Yes No Have you ever received a facial?* Yes No Have you ever had a chemical peel?* Yes No Have you ever had microdermabrasion or laser treatment?* Yes No When was the last time you received either of these treaments?* MM slash DD slash YYYY Terms and conditions* I acknowledge the following is true and agree to these terms.I have completed this form to the best of my ability and knowledge AND agree to inform the technician of any changes in the above information. I have been informed and understand the contraindications to the requested treatment(s) 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 consent to before and after photos.* Yes No NameThis field is for validation purposes and should be left unchanged.
