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Home
About Us
Services
Facials
Massage
Waxing
Holistic Health
Permanent Makeup
Lift & Tint
Body Treatments
Threading
Lash Extensions
Individual Service Packages
Spa Day Packages
Pricing
Policies
Shop
Forms
FAQ
Contact Us
Facial Form
Name
*
Phone
*
Email
*
Birthday
*
Mailing Address
*
City
*
State
*
Zip
*
Emergency Contact
*
Emergency Contact Phone Number
*
What would you like to achieve with your skin treatment today?
*
Have you had a facial treatment/chemical peel before?
*
Yes
No
Do you have any special skin problems or concerns?
*
Yes
No
If yes, please describe:
Are you presently under a physician's care for any skin condition or other related problems?
*
Yes
No
If yes, for what?
Are you currently taking any antibiotics?
*
Yes
No
Have you ever used Hydroquinone?
*
Yes
No
If yes, how long ago?
Do you currently use wax, electrolysis, or depilatories, or any form of hair removal on your face?
*
Yes
No
If yes, what kind?
Have you ever been diagnosed with skin cancer?
*
Yes
No
If yes, where?
Do you wear sunscreen on a regular basis?
*
Yes
No
Do you have any metal implants?
*
Yes
No
If yes, where?
Do you smoke regularly?
*
Yes
No
Do you have permanent makeup?
*
Yes
No
If yes, where?
Send