Buccal Ritual Intake Form

First name

Last name

Birthday

Month

Day

Year

Phone

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:

Are you currently taking any medications or using any medical devices (including implanted devices)? If yes, please provide details below.

Claustrophobia?

Sensitivities to light, touch, sound, or smell? Please explain?

Allergies:

Contact lenses?

Hair extensions?

Photo & Media Consent

Multi choice

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

Signature

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Date:

Buccal Ritual Intake Form

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