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THE SIGNATURE RITUAL FACIAL
THE SCARED MOTHER RITUAL FACIAL
THE BUCCAL RITUAL
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Last name
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Birthday
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Phone
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Emergency Contact Name & Number:
Relationship:
Area(s) of concern on face & goal with the Buccal Ritual:
How would you describe your skin? (Dry, Oily, Combination, Changes Seasonally):
Are you pregnant, trying, perimenopausal, menopausal, experiencing hot flashes, or have you given birth within the last 30–60 days? If yes, please explain and list delivery date if applicable:
Current skincare routine/products used:
Any harsh treatments in the last 30 days (chemical peel, laser, etc.)?
Have you had Botox, filler, facial surgery, or sinus surgery in the last 30–60 days? If so, what & when:
Facial tattoos in the last 30 days?
Have you had a cold sore in the last 30 days?
Sinus issues – current, ongoing, or seasonal?
TMJ, teeth grinding/clenching, jaw pain – current, at times, ongoing? Do you wear a retainer?
Do you have gum sensitivity or any ongoing infections in the mouth that I should be aware of?
Teeth issues or recent dental work in the last 30 days? Please explain:
Thyroid issues?
Are you currently under any medical treatments (such as chemotherapy, radiation, or anything that may cause skin sensitivity)? Please explain:
Claustrophobia?
Sensitivities to light, touch, sound, or smell? Please explain?
Allergies:
Contact lenses?
Hair extensions?
Photo & Media Consent
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Yes, may be used publicly on website, social media, or marketing materials
Yes, for educational purposes only (not publicly posted)
No, I do not consent to photos or videos being taken or used
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