Intake Form - Skincare by Me2Beauty

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone *

Referred by:

Reason for visit: *

Medications:

Have you had a facial before? If yes, how long ago?

Have you had any chemical peels? If yes, how long ago?

What other facial services/treatment have you had?

Allergies?

Do you take any supplements, herbs, or vitamins? Please specify.

Have you been exposed to any tanning method in the past 24 hours?

Yes
No

Do you smoke?

Yes
No

Do you get sore/fever blisters?

Yes
No

Are you pregnant or trying to get pregnant?

Yes
No

Are you epileptic or suffer from seizure, have any metal implants, or pacemaker?

Yes
No

Describe your skin

Agreement *

I agree

By checking this box I fully understand all of the questions above and have answered them correctly and honestly. Furthermore, I know that it is my responsibility to alert the technician, upon every visit, about recent medical or physical conditions that have occurred. Without the above disclosure, I understand that the attending technician cannot optimize the effectiveness of any treatments or therapies. By checking this box, I consent to all procedures and treatments done at this facility and do not hold the technician or facility responsible for any complications incurred during any treatments and procedures today or in the future.

Cancellation Policy *

I agree

By checking this box I agree to the following cancellation policy: In the even you must cancel or reschedule an appointment, please allow 24 hours. No shows will be charged in full. Late arrivals will receive the best possible service in the remainder of their allotted time.

NEW CLIENT INTAKE FORM