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Facial Intake Form

**Please arrive without makeup to your appointment**

Please read each statement, initial in each box and sign this document to accept your acknowledgement and agreement of the following:

I affirm that I am 18 years of age or older, and competent to sign this release on my own behalf or have a parent with me that consents to this service. 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 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 employer for any injury or damages incurred due to any misrepresentation of my health history. This agreement will remain in effect for this procedure and all future procedures conducted by my technician. Although it is impossible to list every potential risk and complication, I have been informed of possible risks and complications. I have also, to the best of my knowledge, given an accurate account of my medical history, including known allergies or prescription drugs or products I am currently ingesting or using topically. The nature and purpose of the products to be used in this service has been explained to me, along with the risks and hazards involved. 

Which aroma(s) do you prefer? (Please select all that apply):
Conditions you are currently experiencing today (Please select all that apply):
What type of skin do you have?:
What areas of concern do you have regarding your skin?:
Have you been under the care of a dermatologist within the past year?:
Do you have any metal implants?:
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?
Have you received Botox, Restylane, or Collagen injections in the last 6 months?:
Are you taking any medications (particularly hormones, acne medication such as Accutane, antibiotics, Differin, Retinols or blood thinners such as aspirin or Coumadin?:
Have you had microdermabrasion, laser hair removal, electrolysis, deep chemical peel, facial surgery or laserresurfacing or used scrub, glycolic, tanning bed or facial waxing in the last 30 days?
Do you smoke regularly?:
Do you participate in vigorous aerobic activity or sports?:
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