LuxuryBeauty
Luxury Beauty

Client Intake FormFacial Treatment

Please fill out this form completely before your appointment.

Personal Information

Skin Goals

Health Questionnaire

Is this your first facial?
Are you pregnant?
Are you taking birth control pills?
Are you under a physician's care for any current skin condition or other problem?
Are you using (or have used) Azlex, Differin, Renova, Retin-A, Tazarac, Glycolic or Alpha Hydroxy Acids?
Are you now using or have you ever used Accutane?
Do you wear contact lenses?
Are you presently taking any medications?
Have you had skin cancer?
Do you often experience stress?
Do you smoke?

Medical Conditions

Please check if you are affected by or have any of the following:

Consent & Signature

I have read the above information and have given an accurate account of the questions. If I have any concerns, I will address these with my esthetician before the service. I understand that the services offered are not a substitute for medical care and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I give permission to my esthetician to perform the facial service and will not hold the esthetician nor Luxury Beauty accountable for any liability that may result from this treatment. I understand that the information herein is to aid the therapist in giving better service and is completely confidential.

All information is kept strictly confidential and used only for treatment purposes.