Sign Up for Your Next Facial Appointment

Name:

Phone:

Email:

Address:

City/State/Zip:

Date of Birth

Occupation:

What would you like to achieve from your treatment today?

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About Your Skin Care

Have you had a facial treatment before?

If yes, please describe when and what treatment:

Have you ever had a body spa treatment before?

If yes, please describe when and what treatment:

Which of the following best describes your skin type?

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

If yes, please specify.

Have you ever had chemical peels, laser treatments, or microdermabrasion?

Have you used acne medication?

If yes, please specify when and which medication:

Have you experienced Botox, Restylane, or Collagen Injections?

If yes, please specify:

What areas of concern do you have regarding your skin, eye area, or lips? Please describe:

List all known allergies:

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Future Appointment / Contact

May I call you at the provided phone number to confirm future appointments?

May I contact you via mail/email about future promotions and news?

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I understand, have read, and completed this questionnaire for Integrated Bodywork Clinic 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 institutions and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

Check I understand to formally imply your compliance with the above statement:

I Understand

Enter your name as a formal signature:

Enter date signed:

Intake Form - Facial