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Pink Sugar

New Client Intake Form

Welcome to Beauty Journey! We're thrilled to have you with us. To ensure we provide you with the best possible service and tailor our services to meet your unique needs, we kindly ask you to complete our Client Intake Form accurately. Your details are invaluable in helping us create a personalized and enjoyable experience for you. Rest assured; all information shared will be treated with the utmost confidentiality. Thank you for your cooperation, and we look forward to pampering you on your Beauty Journey!
How did you hear about us?

Contact Information

Let's Unveil Your Glow!

At Beauty Journey ALL SKIN IS BEAUTIFUL!

Is this your first facial?
Are you currently under a physician's care for any current condition?
Hany you any of the following treatments in the last 6 months?
Do you sunbathe or use tanning booths?
Are you pregnant or lactating?
Have you taken any of the following in the last 12 months?
Do you smoke?
Have you had skin cancer?
Do you have any neck or shoulder pain?
What steps are you currently using in your skincare routine? ( Select all that apply)
What are your primary skincare concerns?
Have you ever had any of the following allergy reactions ?
Check if you are affected by or have any of the following:

Mind & Body

CHECK YOUR TOP 2-3 CONCERNS THAT YOU ARE SOMETIMES AFFECTED BY:

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

I UNDERSTAND, HAVE READ AND COMPLETED THIS QUESTIONNAIRE TRUTHFULLY. I AGREE THAT THIS CONSTITUTES FULL DISCLOSURE, AND THAT IT SUPERSEDES ANY PREVIOUS VERBAL OR WRITTEN DISCLOSURES. I UNDERSTAND THAT WITHHOLDING INFORMATION OR PROVIDING MISINFORMATION MAY RESULT IN CONTRAINDICATIONS AND/OR IRRITATION TO THE SKIN FROM TREATMENTS RECEIVED. THE TREATMENTS I RECEIVE HERE ARE VOLUNTARY AND I RELEASE THIS INSTITUTION AND/OR SKIN CARE PROFESSIONAL FROM LIABILITY AND ASSUME FULL RESPONSIBILITY THEREOF.

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