Facial Intake Form | Renee Jean

Contact Information

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Intake Questions

The following information will be used to determine your treatment plan using professional grade products. Please be truthful and thorough with this information to ensure you Esthetician can properly analyze and treat your skin. All information is confidential.

Do you smoke?*

Yes
No

Do you wear contact lenses?*

Yes
No

Are you on hormone therapy?*

Yes
No

Are you taking oral contraceptives?*

Yes
No

Have you undergone any surgery in the last year?*

Yes
No

Are you under a physicians care?*

Yes
No

Have you had health problems past or present? Check all that apply.*

Cancer
Heart Problems
Thyroid
Diabetes
Metal Implant or Pacemaker
Other

If other, please elaborate...*

Please list any medications and vitamins you are taking.*

Medication / Vitamin	Reason

Are you pregnant or trying to become pregnant?*

Yes
No

Do you have any skin problems?*

Yes
No

If yes, what kind?*

Do you use Retin A, Tazorac, Differin or Azlexa?*

Yes
No

Have you ever used Acutane?*

Yes
No

Have you had injectables in the last 2 months? (Botox/Filler)*

Yes
No

Have you had any chemical peels, microdermabrasion or laser treatments within the last month?*

Yes
No

What type of skincare are you currently using?*

Soap
Cleanser
Toner
Scrub/Peel
Moisturizer
Sunscreen
Other

Have you ever had a reaction to skincare products?*

Yes
No

What pressure do you prefer during massage?*

Light
Medium
Firm

Do you have ANY allergies or sensitivities?*

By digitally signing below I understand; have read and fully completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes and previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I do understand that not all treatments will have the same results on every client, therefore no guarantee can be given. I also understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I agree to inform the Esthetician of any skin irritation in the following days after receiving treatment. I am aware that it is my responsibility to inform the technician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release ReneeJean Make-up LLC & the Esthetician performing the services, from liability and assume full responsibility thereof.*