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Please fill out the following form
after booking your appointment. Forms must be submitted before your session begins.

Facial Intake Form
MEDICAL HISTORY
Please check all that apply:
Please check all that apply:
Are you currently taking any medications?
Do you have any allergies?
Have you had any facial or dermatology services in the past 30 days?
SKIN CARE HISTORY
Check the products that you currently use (Please check all that apply):
What type of skin do you have?
Conditions you are currently experiencing today? (Please select all that apply):
IMPORTANT INFORMATION
What concerns do you have regarding your skin? Please select all that apply. Required
Have you been under the care of a dermatologist within the past year?
Have you used Retin-A, Renova, AHAs or Retinal/Vitamin A products in the last three months?
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I 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 liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

Please read each statement, check off each box and sign the end of this document to accept your acknowledgement and agreement to the following:

 I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages that might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose name appears above, responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.

Release by Parent/Guardian of Minor Child

I am the Parent or Legal Guardian of the minor named above, and have legal authority to execute this release on his/her behalf. I have read and fully understand the contents of this release, and consent to the release.

Thanks for submitting!

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