Jennie Fresa Facial Intake Form 2024/25

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Email *

Date *

YYYY

First and Last Name *

Phone Number *

Address

Date of Birth

YYYY

Are you? *

Female

Male

Non-binary

Prefer not to say

Other:

How would you like to be addressed? *

When is the last time you had a facial? *

How did you hear about Jennie? If it's a human, she would like to thank them. *

I'm okay with (check all that apply) *

AHA's (Glycolic or Lactic)

Steam

LED light therapy

Face, Shoulder and Arm Massage

Home care recommendations

Near Infrared technology

Cold Therapy

Enzymes exfoliation

Dermaplaning

Extractions (if needed)

Microcurrent lifting and toning

High Frequency for breakouts

Oxygen dome or spray

Other:

Possible contraindications to LED or devises that use currents like RF or micro current (check any that apply) *

Epilepsy

Light sensitivity

Topical steroids

Thyroid condition

Herbs- St johns wart or psoralen

Photosensitive drugs

Cancer

Accutane

Diabetes

Impetigo

Pace maker

Metal plates

Viral infection

Pink eye

Hordeola (infection of the sebaceous gland)

Furuncle (inflammation of the hair follicle)

Auto immune disease

Other:

Are you pregnant? *

Yes

Other:

If so, how far along? *

Are you under the care of a dermatologist? *

Yes

Other:

If yes, for what reason? *

Tell me about your skin (click all that apply) *

Dry/Dehydrated

Oily

Sensitive

Combination

Acne Prone

Option 6

Other:

What areas of concern do you have regarding your skin (check all that apply) *

Breakouts/Acne

Uneven skin tone

Wrinkles or fine lines

Rosacea

Redness/Rudiness

Sun or Brow Spots

Black heads or white heads

Excessive oil /shine

Dull /Dry (lack of oil in the skin

Dehydration (lack of water in the skin)

Milia

Other

Other:

Required

Are you allergic to... *

Cosmetics

Food

Sunscreen

AHA's

Shellfish

Numbing creams

Medicine

Animals

Drugs

Pollen

Fragrance

Latex

Ingredients

Other

Other:

If yes, please explain *

Conditions you are currently experiencing *

Headache

Muscle cramps

Fatigue

Stress

Inflammation

Anxiety

Insomnia

Forgetfulness

Other

Other:

Do you have any medical conditions including a compromised immune system or claustrophobia that I should be aware of? *

Yes

Other:

If yes, please explain *

Will you be wearing contacts during your facial? *

Yes

Other:

I will follow your lead, what do you prefer during your facial? *

Silence

A little conversation to start

Conversation

I'd love at home recommendations at the end of facial.

Other:

Do you currently or have you used in the last 7-10 days, Retin-A, Renova, AHA's over 30%, Retinol or Vitamin A derivative products? If so, please stop using 72 hours prior to your facial *

Yes

Have you received Botox, Restylane, or Collegan injections in the last 6 months? *

Yes

Tell me about you lifestyle and diet *

I drink more than 16 oz of water daily

I have a regular AM + PM skincare routine

I eat a healthy diet with veggies, fruits and grains

I sleep with my makeup on

I try to limit my salt, sugar and alcohol intake

I get 7-8 hours of good sleep

I travel

I exercise at least 2x per week

I smoke

I can use some dietary and lifestyle suggestions

Option 11

Other:

Required

In your words, tell me what your skincare goals are *

Our Cleanliness Commitment to you:

All treatment areas will be sanitized before and after every client. We use eco-friendly hospital grade disinfectant along with alcohol to ensure proper cleaning standards.

CANCELLATION POLICY:

Your appointments and well-being are very important to us. Any appointments that need to be cancelled must be done no later than 48 hours before the time of your appointment. Past this time frame, you will be charged 50% of your cancelled appointment cost. This amount cannot be applied to future appointments or refunded under ANY circumstances.

In the event that you no show for your appointment, you will be charged 100% of your appointment cost and the amount cannot be refunded or applied to future services under ANY circumstances.

All policy fee's must be paid to resume any future appointments.

Jennie Fresa reserves the right to decline any person(s) from booking future appointments if any issue(s) persist.

LATE POLICY:

If you are more than 15 minutes late for your service, we may not be able to accommodate you. In this case, the same cancellation fee will apply. We will do our very best to reschedule your service for another time that is convenient to you.

We require a credit card to hold your appointment. Cancellation fees will be charged to your card on file.

Please write your name below to acknowledge you have read and agree with the above terms and policies. *

Send me a copy of my responses.

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