Client Information

Full Name *

Email *

Phone *

Date of birth *

Address

Street Address *

City *

State *

Postal Code *

Emergency Contact Name *

Phone Number *

Relationship *

Skin History

Do you have any skin allergies? *

Yes

Have you ever had any adverse reactions to facial products or treatments? *

Yes

Are you currently using any prescription skincare products? *

Yes

Do you have any existing skin conditions (acne, rosacea, eczema, etc.)? *

Yes

Have you had any recent cosmetic procedures (Botox, fillers, chemical peels, etc.)? *

Yes

Health History

Are you pregnant or breastfeeding? *

Yes

Have you ever had a history of skin cancer? *

Yes

Do you have any medical conditions we should be aware of? *

Yes

Are you currently taking any medications? *

Yes

Have you had any recent surgeries or medical procedures? *

Yes

Skincare Routine

Describe your current skincare routine (cleanser, moisturizer, sunscreen, etc.) *

How often do you cleanse your face? *

How often do you exfoliate your face? *

Do you use any retinol or acids in your routine? *

Yes

Do you use sunscreen daily? *

Yes

Treatment Preference

What specific facial concerns would you like to address? *

What type of facial treatment are you interested in (e.g., hydrating, deep cleansing, antiaging, etc.)? *

Do you have any preferences or restrictions on the products used during the facial? *

Are you interested in additional treatments such as extractions, masks, or massage? *

Yes

Have you had professional facials before? *

Yes

Any additional notes? *

By signing below, I understand that the esthetician will analyze my skin and recommend treatments/products based on my skin concerns and health history. I consent to these recommendations and understand that results may vary. I confirm that the information provided above is accurate to the best of my knowledge.

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