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Facial Intake Form

First Name

Last Name

Birthday

Gender

Male

Female

Other

Select an Address

PERSONAL HEALTH HISTORY

Do you have any of the following conditions? If yes, please select them.

Blood Clot Disorder

Blush Easily

Bruise Easily

Cancer

Circulation Disorder

Claustrophobia

Depression/Anxiety

Diabetes

Eczema

Epilepsy or Seizures

Heart Disease

Hepatitis A/B/C

HIV AIDS

Hormonal Imbalance

Hypertension

Hypotension

Hysterectomy

Immune Disorder

Keloid Scaring

Lupus

Menopause

Metal Implants

Migraines/Headaches

Other

Pacemaker or Defibrillator

Psoriasis/Rosacea

Skin Diseases

Spinal Cord Injury

Thyroid Disorder

Varicose Veins

Fibromyalgia

SKIN CARE HISTORY

Do you have any of the following conditions? If yes, please select them.

Normal

Oily

Dry

Acne

Other

How does your skin heal?

Your current skin products:

Fast

Slow

Pigments

Scars

Product Names(s)

Purpose of Product:

Other

Frequency Used:

Eye Make-Up Remover

Cleansing Cream

Facial Soap

Skin Toner/Astringent

Body Soap

Day Cream

Night Cream

Eye Cream

Neck Cream

Hand Cream

Mask

Facial Scrub

Exfoliants

Body Lotion/Cream

Body Scrub

Social History

Are you pregnant?

Yes

Are you trying or planning to be pregnant?

Yes

Are you currently unde any kind of diet

Yes

Are you wearing any contact lenses

Yes

Are you breastfeeding?

Yes

TERMS & CONDITIONS

I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information.

I hereby agree to allow Tiffany Keowan to use my photos or video for social media and to track my treatment progress

Yes

I confirm that all information in this form is true and accurate.

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

I understand and agree to the terms and conditions

Your Signature (Device dependent: use trackpad, mouse, finger or stylus)

Todays Date

TK Esthetics, llc

Certified Esthetician services in

Springfield, MO

Book Now

Info

1343 E Montclair St

Springfield, MO 65804

Email Us Now

Tel: 417-241-1558

Opening Hours

Mon - Fri: 10am - 8pm

Sat: 10am - 4pm

Sun: Closed

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