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Majestic Spa & Salon Facial Intake Form
Confidential Information for Esthetics
Welcome! We want to make your appointment as pleasant and comfortable as possible. If at any time you have any questions regarding your visit, please let us know.
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Email
*
Your email
Name
(Please Print)
*
Your answer
Phone Number
*
Your answer
Referred By
Your answer
Zip Code
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Have you ever had a facial treatment before?
*
YES
NO
Do you have any special skin problems or concerns pertaining to your face?
Please Specify
*
Your answer
Have you ever had a chemical peel, laser treatment, or microdermabrasion?
If yes, when?
*
Your answer
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/Vitamin A derivative products?
Please Specify
*
Your answer
Have you used an acne medication in the last 6 months?
*
YES
NO
Have you experienced Botox, Restylane, or Collagen injections in the last 6 months?
If yes, when?
*
Your answer
Do you have any allergies?
Please specify
*
Your answer
What would you like to achieve from your treatment today?
*
Your answer
FEMALE CLIENTS
Are you pregnant?
YES
NO
Clear selection
Are you lactating?
YES
NO
Clear selection
Do you have any menopause problems?
YES
NO
Clear selection
Are you undergoing any hormone therapy?
YES
NO
Clear selection
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