Teen Facial Intake Form

Date of Appointment*
Date Format: MM slash DD slash YYYY
Name*
First Last
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
1. What is the goal for your facial today?*
2. Do you have any allergies?*
If Yes, Please List
3. Are you using any prescriptions?*
If Yes, Please List
4. Are you currently using products containing Benzoyl Peroxide, glycolic acid, salicylic acid or Retin-A or retinol?*
If Yes, Please List
5. Extractions are often part of the Teen Facial if they are needed. The process may cause discomfort as pressure is applied to the skin surrounding the comedone or blackhead. Occasionally there may be a temporary mark left on the skin depending of the stubbornness of the congestion. Do you wish to proceed with extractions?*
6. Occasionally an Alpha-hydroxy peel is recommended to help decongest pores and slough away layers of dull, dry skin. From time to time this may cause temporary redness and excess flakiness of the skin as the dead skin sloughs away. If the esthetician recommends an Alpha-hydroxy peel would you like to proceed?*
Parent or Guardian E-Signature*
Date*
Date Format: MM slash DD slash YYYY
Teen E-Signature*
Date*
Date Format: MM slash DD slash YYYY