Skincare Client Intake Form
New Facial client information
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Email *
Name *
Date *
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Address *
Cell Phone (we text appointment reminders) *
Can we use your email for newsletter and promotions?
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Birthday (we send birthday coupons) *
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How did you hear about us? *
Is this your first facial?
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If No, When was your last facial?
What is the main concern(s) with your skin? *
Are you currently under a physician's care for a skin condition? *
Are you Pregnant? *
Are you nursing? *
Are you currently or in the past 12 months taken Accutane or other oral Acne medication? *
Are you currently or in the past 3 months taken Retin-A, Retinol, or other powerful Hydroxy Acids? *
Have you had a chemical peel within the last 6 months? *
Have you had an IPL/Laser Facial within the last 3 months? *
Are you exposed to extended periods in the sun or are you planning a vacation with extended periods in the sun in the near future? *
Are currently under any medication? (Please list) *
Do you have or have you previously been treated for skin cancer? (what type) *
Please check if you are affected by any of the following: *
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Are you allergic to any of the following: *
Required
Have you ever had an adverse reaction to a skincare treatment? (explain) *
Do you smoke?
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Are you claustrophobic?
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Are you currently wearing contact lenses? *
What is your stress level on a scale of 1-5?
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What skincare products do you use currently?
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above form and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold esthetician, nor Glow Organic Wellness Spa, responsible for any of my conditions that were present, but not disclosed at the time of the skincare procedure, which may be affected by the treatment performed today. *
Required
Signature of Client (please type your name) *
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