Facials Form

Name *

First Name

Last Name

Phone

(###)

###

####

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

Headaches/ Migranes

None

Do you get claustrophobic? *

Please note that if you are coming to the Home Private studio space that it is a small space and not suitable for clients who are claustrophobic.

Yes

No

Do you currently suffer from any of the following? *

Open Cuts

Open Wounds

Open Lesions

Broken Vessels

None of the above

Please rate your current stress level *

Low

Moderate

High

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? *

Waxing/sugaring

Threading

Laser/Electrolysis

None

Do you currently use any of the following?

Accutane

Retin-A

Prescribed topical cream

Are you currently using any products that contain:

AHA (glycolic acid- lactic acid- etc.)

BHA (salicylic acid)

Vitamin A derivative (retinol/retonids)

Exfoliating scrubs

Have you received any of the following in the last week: chemical peels, laser services, or microdermabrasion treatments?

It is not recommended that any of the services be done within the week of your facial.

YES( within the last month),

YES,(within the last 2-3 months)

Do you...

Wear contact lenses

Have a pacemaker

Have metal implants

Smoke

Frequent tanning beds

What is your preferred level/frequency of conversation with your service provider during a spa service? *

Very little to none

Moderate

Chatty

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 50% 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