Facial Form

Facial Form

 

Portrait of an attractive young couple lying on massage bed at spa
Portrait of an attractive young couple lying on massage bed at spa

First Name (required)

Last Name (required)

Phone Number (required)

Your Email (required)

How did you hear about us? (required)

Facial Skin Types: (required)
NormalOilyDryCombinationSensitiveAcneMature

Present Skin concerns:
Hyper/PigmentationDhydrationRosaciaBlackheads
WhiteheadsMelasma (Dark Patches)Dilated PoresSun Damage
BlemishesAcne ScarsEnlarged Pores

Prescribed Medications:
AntibioticsAccutaneRetinA
CortisoneCleosinE Mycint

Have you ever used:
Benzyl/PeroxideSulfaSalicylic/Glycolic AcidBleachNone

Allergies?

Do any of the following apply to you?
SmokeExerciseWear Contact Lenses
Eat Spicy FoodsBurn EasilyTan Easily

Have you ever been diagnosed with any of the following?
AnxietyDepressionMigrainesAsthma
Sinus ProblemsHigh/Low Blood PressureCancer
DiabetesThyroidEpilepsyHeart Problems
HemophiliaHepatitisHerpesHIVOther

Emergency Contact (name, phone & relationship): (required)

Notes:

I hereby give my consent and authorization voluntarily and release Picasso Day Spa & Salon and the aesthetician assigned to me from any claims; implied or stated that I have or may have in the future in connection with this treatment, regarless of results. By checking the box below I am stating I fully understand all of the above and that the treatments process has been satisfactorily explained to me.

Check to agree. I agree.

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