Facial Intake Form 

Contact Information
Name *
Today's Date *
Today's Date
Phone Number
Phone Number
Address *
Birthday *
We confirm appointments the day before. What is the easiest way for you to reply back to a confirmation? *
Health & History
Is this your first facial?
Are you presently under a physicians care for any skin condition?
Are you pregnant?
Are you nursing?
Are you currently using (or have used in the past)? Please check
Do you have or have you had skin cancer?
Please check if you have any of the following:
Are you allergic to any of the following? Please check.
Do you smoke?
Do you often experience stress?
Are you claustrophobic?
Your face will partially be covered with a warm towel.
Please list.
Please list.
Have you ever had a:
What is your skin type?
Any dermal injections or fillers within the last 6 months?
Skin Care Consent
Please type your name.
Please type your name.
I certify that the above information is correct to the best of my knowledge. In accordance with law, Esthetics/Skin Care professional cannot cure, treat, prevent or diagnose any condition. These treatments are used as regimens for improving skin appearance and wellness. Information exchanged during any session should be given at my own discretion. Because certain esthetics treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the Skin Care professional updated as to any changes in my health prior to any future sessions and understand that there shall be no liability on the Skin Care professional’s part nor on the part of Echelon, and its affiliates should I fail to do so. The Skin Care professional reserves the right to refuse service to anyone for any reason. I fully understand that the Skin Care professional performs her services within the parameters of esthetics, using skin care treatments. I fully understand that the esthetics professional is not a physician, dermatologist, or psychiatrist and does not portray herself to be. If I experience any pain or discomfort during the session, I will immediately inform the Skin Care professional so that the products and/or techniques may be adjusted to my level of comfort. By signing below I acknowledge that I have read and understand all parts of this consent/intake form, and I have had the opportunity to ask any questions with regard to any services offered. All client information is confidential.