608 West Peace Street, Raleigh, NC 27605

Facial Consultation Intake Form

First Name *

Last Name *

Mobile *

Landline

Email *

Street Address

City

State

Country

Postal code

Date of birth *

Gender

Female

Male

Do you work outdoors?

Yes

No

If no, what type of environment do you generally work in?

Referred By:

What are your treatment objectives today?

Brighter Skin

Anti Ageing

Moisturise Dehydrated Skin

Other

If Other, please give details

Have you had a facial treatment before?

Yes

No

If yes, when?

Have you ever had a body spa treatment before?

Yes

No

If yes, when?

Please give details of any body treatments

Which of the following best describes your skin type?

Do you have any special skin problems or concerns pertaining to your face or body?

Yes

No

If yes, please specify

Have you ever had chemical peels, laser or microdermabrasion?

Yes

No

If yes, please specify including dates

Have you had any recent tanning bed or sun exposure that changed the colour of your skin?

Yes

No

If yes, please give details:

Have you experienced Botox, Restylane, or Collagen injections?

Yes

No

If yes, please give details including dates

If you are underage for this treatment this salon cannot proceed with the service without the consent of a parent or guardian.

If you have any medical conditions or are on any medication you should check with your doctor before having this treatment. We will need to ask you some health questions to ensure a safe service and to provide industry speci c advice, as this treatment may not be suitable for you if you suffer from the below conditions or are on certain medications.

Where we collect information about your health or medical circumstances, we have a legal obligation to collect this information for health & safety and insurance purposes and only do so with your explicit consent. The privacy and security of your data is very important to us and we will only use health related information for the purposes described on this form and in our Privacy Notice.

Therapist

Date:

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are

voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

I have been given, and understand, all relevant pre and post care information on the service that I have received. I understand the procedure and I do not hold the therapist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed, which may be affected by the service performed today.

I agree to Cancellation Policy provided by the company. Our cancellation/rescheduling policy requires at least 48 hours' notice for individual appointments and 14 days for group bookings

I agree to Privacy Policy provided by the company.