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Home
About
Facials
All Facial Services
MoveoGlo Laser Facials
Signature Facials
Microneedling
Microdermabrasion
Microcurrent
Chemical Peels
Dermaplaning
Broken Capillary Facials
Acne
All Acne Services
How Our Acne Program Works
Acne Reducing Treatments
Acne Scars Treatments
8 Week Case Study
Pore Clogging Ingredients
Benzoyl Peroxide Use in Acne
Acne Podcast Episodes
Japanese Head Spa
All Head Spa Services
Head Spa Services
FAQ – Head Spa in Peoria
Hair Removal
All Hair Removal Services
Laser Hair Reduction
Female Brazilian
Female Waxing
Male Waxing
Manscaping
Laser FAQ's
Before & After Waxing
Waxing FAQ's
Spray Tanning
All Spray Tanning Services
Bridal Tanning
Male Spray Tanning
Female Spray Tanning
Spray Tanning FAQ
Before and After Spray Tanning
spray tanning pricing
Age Requirements
Lashes & Brows
All Lash & Brow Services
Volume Eyelash Extensions
Modern Lash Looks
Eyelash Extension Care
Brow Treatments
Lash Lifts
Lashes FAQ's
Injectables
All Injectable Services
Botox
Botox Pro Tips
Lip Flips
Shop
Peoria, IL
(309) 219-1140
Book Now
Please input the hardcopy information from the Facial & Waxing Intake Form:
1. Demographics Information
Intake Date *
First Name *
Last Name *
Gender
Please select one
Male
Female
Date of Birth
Street Address
City
Zip/Postal Code
Cell Phone
Email *
Would you like to be on our Email Newsletter and receive special?
Yes
No
2. Skin Care Treatment Background
Have you ever had a facial before?
Yes
No
Have you ever had waxing before?
Yes
No
If yes, where?
Soderstrom, Five Senses, other major competitor
Out of the area
If yes, how long ago?
Please select one
Within the two months
3-6 months ago
6-12 months ago
1 year ago
2+ years ago
Exposure to the sun
Never
Light
Moderate
Exessive
Have You Used Accutane in the last 12 months?
Yes
No
Have You Used Retin-A in the last month?
Yes
No
Other Oral or Topical Skin Medications in the last 6 months?
Yes
No
Other oral/topical skin medications in the past 6 months?
Yes
No
If yes to other oral/topical medications, please describe
Are you using any of the following?
AHA's
Salicylic Acid
Retinol
Have you had chemical peels, microdermabrasion or resurfacing?
Yes
No
What brand of prodcuts do you use?
cetaphil
Soderstrom brand
Rodan & Fields
Other
What cleanser skin product do you use?
Toner product do you use?
Moisturizer product do you use?
Serum product do you use?
Masque product do you use?
Exfoliator product do you use?
My treatment goals are:
Anything else we should be aware of before starting?
3. Medical/Health Background Information
Are you pregnant?
Yes
No
If yes, how far along is your pregnancy?
Please select one
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
Exposure to Sun?
Never
Light
Moderate
Excessive
Food allergies?
Yes
No
Allergies to latex?
Yes
No
Other allergies?
Yes
No
Allergy Notes
Are you currently on any medications?
Yes
No
If Yes, please list any medications:
Do you have (select all that apply):
Epilepsy
Heart condition
Pacemaker
Skin cancer
Skin Diseases
Recent operations
Submit