Name *

First Name

Last Name

Are you currently under the care of a physician or medical professional? *

Yes

No

Are you currently: *

Pregnant

Breastfeeding

Neither

Have you experienced any of these health conditions past or present? *

Hormone Imbalance

Cancer/ Systemic disease

High Blood Pressure

Diabetes

Heart problems

Arthritis

Auto-immune Disorder

Asthma

Epliepsy/Seizures

Cold sores

Herpes

HIV/AIDS

Lupus

Depression/Anxiety

Allergy to Asprin

Headaches/ Migranes

None

Do you currently suffer from any of the following? *

Open Cuts

Open Wounds

Open Lesions

Broken Vessels

None of the above

Which of the following best describe your skin? *

Normal (-no visible blemishes- fine pores - smooth texture)

Sensitive (-reactive to fragrance -often irritated)

Combination (-oily and dry patches -oily t-zone -hormonal breakouts)

Oily (-enlarged pores -excessive oil)

Acne (-cystic or nodules)

Dry (-dull -visible lines and wrinkles -feels tight)

Have you been diagnosed with any of the following?

Eczema

Psoriasis

Rosacea

Have you received any of these facial hair removal services in the last 7 days? *

If so, we recommend doing these services at least 7 days prior to your treatment to avoid reactions or irritations.

Waxing/sugaring

Threading

Laser/Electrolysis

None

Do you currently use any of the following?

If so, please stop the use of them 7 days prior to your treatment.

Accutane

Retin-A

Prescribed topical cream

Any Vitamin A or Retinol derivative

Have you used Accutane within the last year?

If so, a doctor's note is required to state that you are able to receive a facial.

yes

no

Are you currently using any products that contain:

If so, please stop the use of these products 7 days before your service.

AHA (glycolic acid- lactic acid- etc.)

BHA (salicylic acid)

Vitamin A derivative (retinol/retonids)

Exfoliating scrubs

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES( within the last month),

YES,(within the last 2-3 months)

Conversation level *

What level/amount of conversation would you like?

Very little or no chatting

A little bit of chatting

Chatty - let's catch up!

Do you...

Wear contact lenses (must remove prior to treatment)

Have a pacemaker

Have metal implants

Smoke

Frequent tanning beds

Massage

Relaxation and Lymphatic massage are included. Which pressure level do you prefer?

Light

Medium

Deep

I acknowledge that I must adhere to Sam Tran Beauty & Wellness’ policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss 100% of the total service cost. *

Yes

I acknowledge that ANY no show will result in the loss of 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” Policy *

Yes

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. *

Yes

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. *

Yes

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. *

Yes

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments *

Yes

I release Sam Tran Beauty & Wellness and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products. *

Yes