What is your name? *

Phone Number *

Address, City, State, & Zip *

Emergency Contact & Emergency Contact's Phone Number? *

Date of Birth *

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. *