Welcome to the Nourished Family!Please help me get to know you better by completing the following form prior to your appointment. Date MM DD YYYY Name * First Name Last Name DOB * MM DD YYYY Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email How did you hear about Nourished Esthetics? * What is your main reason for booking today's appointment? For Example, relaxation, anti aging, deep cleanse, redness? * What is your Current Skin Care Routine? Please list cleansers, toners, serums, moisturizers, masks, scrubs etc and if they are used AM/PM Have you ever had a skin reaction during or following a facial procedure or facial product? * Any allergies? * Yes No If "yes" please describe in detail the reaction and the allergy source Have you had chemical peels or microdermabrasion in the past 3 weeks? * * If so, please explain below Yes No If yes, please describe details as this could impact the ability to perform your facial today Have you received any of the following treatments within the past 14 days? (check all that apply) * laser botox cosmetic fillers facial tattoo or microblading miccroneedling/ vivace none If "yes", describe: Do you have eye lash extensions that need to avoid steam? * Yes No Do you have a spray tan that requires "tan safe products" * Yes No Are you pregnant or trying to become pregnant? * Yes No Have you been diagnosed with advanced diabetes? * Yes No Have you used Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products in the last three months? * Yes No Have you used Any acne medications? * Yes No If you have received cosmetic fillers or injectables within the last 14 days and do not reschedule your facial appointment, you will be unable to receive a facial and you will not be refunded for the service amount. Your fillers/injectables will be moved around with a facial! this is important! * Please Initial you assume all risk and release all liability when receiving a facial service * Please Initial Failure to answer all questions of this form completely and truthfully can prevent services from being rendered. * Please Initial If you do not cancel and or reschedule your appointment within 24 hours of your appointment time you will be charged a non-refundable $75 fee for the time slot that was reserved especially for you * Please Initial Failure to call or show for your appointment, you will be charged the full-service amount without refund. Please Initial Late and Early Appointment Policy: * The time you book your appointment is especially reserved for you. Please note, the service being rendered begins at the time of appointment. Depending on service being rendered, The service time slot includes check in, check out and dress time. If you are early for your appointment and can be seen at arrival, your service time begins when brought to treatment room. If you are late for your appointment, your service time begins at your originally scheduled time. Please initial below acknowledging the above policy. Client Consent Policy * Please understand that due to mandatory preparations to accommodate allergies that client consent forms must be filled out four hours prior to scheduled appointment time. Failure to do so will result in appointment being rescheduled and a charge of a $75 non-refundable scheduling fee. Please initial that you understand the above client consent policy. Right to refuse service * Please understand that Nourished Esthetics has the right to refuse service to anyone. Please initial that you understand. Use of legal name for any paperwork * It is imperative that any paperwork that is filled out for Nourished Esthetics is filled out with your legal name that matches your driver's license or any government issued id. Please initial that you understand the above Use of legal name policy. GiftCard Redemption? * yes no Thank you for trusting me with your skincare needs!
