Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Email
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Phone
(###)
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What is your preferred method of communication for appointments and service follow-up?
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Have you received the COVID shot (vaccine)? If yes, please list date of final dose. If scheduled, please advise of the appointment date. If you do not plan on receiving it, simply note N/A. Please know this is important as many people have experienced increased sensitivities or side effects that they previously haven't and we want to help troubleshoot should there be any reactions that may be new to you.
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Do you have any known allergies or sensitivities?
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If other, please describe:
Are you currently having or had any of the following medical conditions that may compromise the treatments performed and/or your skin?
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If other, please describe:
Please share your beauty journey goals - both short term and long.
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Please list previous skin, brow, or lash services that you've received and the most recent date of treatment. If this is your first experience with these types of services, please list as such! (and welcome! :))
Are you currently using any of the following?
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If other, please describe:
Are you prone to any of the following?
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If other, please describe:
Please review your current routine & check all that apply:
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If other, please describe:
If you are receiving skin care therapy from us - either facial, vajacial - or a brow service, please describe in more detail specific brands/product names of the items you checked above. This aids in us verifying ingredient decks and any contraindications for treatments. Please also describe the frequency with which you are using these products (e.g. cleansing only in PM, exfoliating 1x/week, etc.) If receiving body hair removal or a lash service, just write N/A.
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Please check all of the following that you consume as part of your nutrition:
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If other, please describe:
Please describe the frequency of the items in your nutrition you checked above or any other restrictions or guides you follow (e.g. coffee 1-2x/day, veggies every meal, social drinker, etc.). This can help us pinpoint any potential triggers for inflammation or areas for improvement that we can help identify.
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How would you describe your water intake? Please share approximate ounces or describe how many bottles you drink.
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Please check the following that are part of your lifestyle or routine:
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