Skin Care Facial Form - Best Hair Salon and Day Spa in ...
[pic]Skin Care Facial Form
Name: _________________________________________________
Address: ________________________________________________
City: ____________________ St: ________ Zip: _______________
Cell Phone: _________________ Bus Phone: __________________
Email: _________________________________________________
Date of Birth: _______________________ Age: _______________
Occupation: ____________________________________________
Have you had cosmetic surgery/non-surgical? Yes No
When? _________________ What Type? __________________
Please Circle Skin conditions you are experiencing
(Hands or Face) -Sun spots -Freckles
(Around Lips) -Fine lines -Wrinkles
(Face or Neck) -Fine lines -Wrinkles
(Around Eyes) -Fine lines -Wrinkles -Dark Circles
(Face, Chest or Back) -Acne Scars -Acne Breakout
-Blackheads -Whiteheads -Clogged Pores
-Loss of Skin Elasticity -Excess Facial Hair
-Dry Chapped Lips -Other_______________________
What is the end result you are expecting for your skin? ___________________________________________
Please list facial products used
Cleanser_________________ Toner___________________
Moisturizer_______________ Night Cream______________
Make up_________________ Other ___________________
Circle any health conditions which you are now experiencing
-Pregnant -Diabetes -High/Low Blood Pressure
-Thyroid -Cancer -Eczema/Psoriasis
-HIV -Hepatitis -Herpes Simplex
-Keloids -Migraine -Active Sores
Circle which applies to your daily routine
-Topical Creams -Retin A -Contact lens -Hormone Therapy
-Dentures -Metal Implants -Birth Control -Acutane
Please indicate the services that best interest you
Chemical peels - Light Therapy - Microdermabrasion
Juvederm - Botox
What is your water intake? ____ cups per day
List any Allergies or skin Reaction
Allergies____________________________________________
Skin Reactions_______________________________________
Products used________________________________________
List all medications you are currently taking in the Last 30days Includes (hormones, birth control, pills, vitamins, herbal supplements etc.)
| Medications | Reasons |Length of Use |
| | | |
| | | |
| | | |
| | | |
Additional Comments:
________________________________________________________________________________________________________
Referred By_______________________________________
(Friend, Ad, Internet, Walk-in etc)
Below is the list of enhancers available to your during your scheduled facial service. Please check your selection for anything you wish to add.
Eye Treatment-$15 _____
Kissable Lip Treatments-$15 _____
Décolleté Treatment-$15 _____
Eyebrow Tint-$16 _____
Eyelash Tint-$25 _____
Eyebrow Waxing/Threading -$17 _____
Lip Waxing/Threading-$15 _____
Glycolic Peel Add on - $25 _____
Antioxidant Add on - $25 _____
Acne Control - $25 _____
Extractions - $25 _____
Speciality Mask $20 _____
I acknowledge that the questions answered above are true and Skin Care Specialist and Sanctuary Salon cannot be held responsible for any reactions that would otherwise be prevented.
Signature Date
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