Facial Discovery Call Client Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Do you have any allergies to food, cosmetics, or drugs? *

Yes

No

If yes, please list:

Please list any other health conditions:

Are you pregnant? *

Yes

No

Are you on birth control or hormone replacement? *

Yes

No

Are you taking any supplements or medications? Please list what you take and what it's for.

Are you under the care of a skin care therapist, physician, or dermatologist? *

Yes

No

Are you or have you been using or taking any of the following? *

Have you had any of the following procedures? *

Laser resurfacing

Chemical peel

Botox or collagen injections

No

Please list any other skin procedures here:

Date of last treatment:

Have you had a facial before? *

Yes

No

Date of last facial:

What are your areas of concern? *

How does your skin react to the sun? *

Do you experience frequent blemishes? How frequently? *

Have you ever experienced burning, itching, redness, or irritation? *

What brand name(s)? *

I want to get awesome health tips, tools and resources to my inbox! *

Yes

No, thank you