Effortless Beauty Clinic: Client Facial Intake Form
Email *
What is your name? *
Phone Number *
Address, City, State, & Zip *
Emergency Contact & Emergency Contact's Phone Number? *
Date of Birth *
MM
/
DD
/
YYYY
What are your main skin care concerns? *
If you could wave a magic wand how would your skin look in one month? *
Any special requests for today? (extractions, skin soothing, skin clearing, hydration, relaxation, waxing) *
Is there anything I need to know before we get started? The more I know, the better your results. (Please List: allergies, sensitivities, pregnant, nursing, health issues, medications, metal plates, cold sores, herpes, Retin A use or any topic products that might cause skin sensitivity) *
What did you LOVE about your last facial, and what could you have lived without? *
Knowing that home care is a big part of achieving beautiful skin, would you like to chat about how to maintain today's results at the end of your facial? *
Anything else you want to share? I love learning about my clients as it helps me provide superior customer service. *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Effortless Beauty Clinic.