UNIQUE IMAGES- FACIAL INTAKE FORM

First Namerequired
Last Namerequired
Date of Birthrequired
Genderrequired

Emailrequired
Phone (Digits Only)required

Occupationtextoptionalno save

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Have you had a Facial before?
If Yes, where and how long ago?textoptionalno save

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Are you Pregnant?
If Yes, how far along?textoptionalno save

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Do you Smoke?
If Yes, how many a day?textoptionalno save

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Do you Drink Coffee or Sodas?
If Yes, how much a day?textoptionalno save

How many glasses of Water do you drink a day?numberoptionalno save

Exposure to the sun (please check):

Never
Light
Moderate
Excessive

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Do you have Food allergies?
If Yes, please specifytextoptionalno save

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Do you have Other allergies?
If Yes, please specifytextoptionalno save

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Do you have Allergies to latex?
If Yes, please specifytextoptionalno save

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Do you take any Medication (topical or oral) for acne?
If Yes, please specifytextoptionalno save

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Have you ever had Chemical Peels, Microdermabrasion or any resurfacing treatments?

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Have you used Accutane in the past 12 months?

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Are you currently on any medications?
If Yes, please listtextoptionalno save

Are you currently using any products that contain the following ingredients? (Check all that apply)

Glycolic acid
Lactic acid
Exfoliation Scrubs
Alpha Hydroxy acids
Vitamin A derivatives

What skin products are you currently using? (Check all that apply)

Soap
Cleanser
Toner
Moisturizer
Serum
Mask
Exfoliate
Eye product

Do you have any of these conditions? (Check all that apply)

Epilepsy
Heart condition
Pacemaker
Skin cancer
Skin Diseases
Recent operations

Do you have any treatment goals?textoptionalno save
Is there anything else that we should be aware of before we start working together?textoptionalno save

In consideration for receiving services at Unique Images Day Spa, I hereby release, waive, discharge, and covenant not to sue Unique Images Day Spa from any and all liability, claims, demands, actions, and causes of action related to any loss, damage, or injury that may be sustained by me or property belonging to me, whether caused by negligence or otherwise, while participating in such activity or while on Unique Images Day Spa premises. I am fully aware of the risks involved and hazards connected with skin care treatments, and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, that may be sustained by me, or any loss or damage to property owned by me as a result of being engaged in such an activity, whether caused by the negligence or otherwise.


Date: 14.01.2020

Time: 10:50 PM

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Submission Sequence: 2020-01-21T16:20:16.640Z0
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