Client Intake | Beauty Journey

Facial Intake

Welcome to Beauty Journey!

We're excited to have you here! Please complete the Client Intake Form accurately so we can personalize your experience. Your information is confidential and helps us provide the best care possible.
Thank you—we can’t wait to pamper you on your Beauty Journey!

First name

Last name

DOB

Address

Phone

If referred, please list their name.

Contact Information

Let's Unveil Your Glow!

At Beauty Journey ALL SKIN IS BEAUTIFUL!

Is this your first facial?

Yes

Are you currently under a physician's care for any current condition?

Yes

Hany you any of the following treatments in the last 6 months?

Chemical Peel

Microdermabrassion

Laser

None

Would you like a quite facial?

Do you sunbathe or use tanning booths?

Yes

Are you pregnant or lactating?

Yes

Have you taken any of the following in the last 12 months?

Accutane

Retin A

Renova or Topical prescription

Not Sure/ Na

Do you smoke?

Yes

Have you had skin cancer?

Yes

Do you have any neck or shoulder pain?

Yes, Today

Sometimes

Never

What are your 2 primary skin care goals?

Please provide the name brands of your current products:

Mind & Body

INITIAL AFTER AGREEING TO EACH OF THE FOLLOWING STATEMENTS:

+ I HAVE NOT HAD ANY LASER TREATMENTS FRAXEL, IPL, HAIR REMOVAL
+ I HAVE NOT HAD ANY MICRODERMABRASION TREATMENTS IN THE LAST 4 WEEKS
+ I HAVE NOT HAD ANY CHEMICAL PEELS ON MY SKIN IN THE LAST 4 6 WEEKS
+ I HAVE NOT HAD ANY FACIAL WAXING IN THE LAST 48 HOURS
+ I HAVE NOT HAD ANY RETIN A RETINOL TOPICAL PRESCRIPTIONS ON MY SKIN IN THE LAST 7 DAYS
+ I HAVE NOT HAD ANY COSMETIC FACIAL INJECTIONS IN THE LAST 4 WEEKS
+ I HAVE NOT HAD ANY FACIAL COSMETIC SURGERY IN THE LAST 12 WEEKS
+ I HAVE NOT USED ACCUTANE IN THE LAST 12 MONTHS
+ I HAVE NOT HAD ANY CHEMOTHERAPY OR RADIATION IN THE LAST 6 MONTHS

INITIAL HERE:

Client Consent & Agreement:

I confirm that I have read, understood, and truthfully completed this form. This serves as full disclosure and overrides any previous verbal or written statements. I understand that withholding or misrepresenting information may lead to skin irritation or contraindications.

I consent to receive services at Beauty Journey Aesthetics and release the institution and its licensed professionals from liability. I take full responsibility for the outcomes of my treatments.

I agree to follow all Beauty Journey Aesthetics policies, including:

Card on File: I authorize a card to be securely stored for booking and payments.
Cancellation Policy: I understand that cancellations with less than 24 hours’ notice or no-shows will result in a 100% service charge to the card on file.

By signing, I acknowledge and accept these terms.

Your Signature

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