Facial Treatment Client Intake Form

Contact Information

Your Skincare Routine

1 begin no stress 10 being lots of stress
Please list all allergies and explain.

I understand, have read and completed this questionnaire 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 irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.