Facial Ritual Follow Up Intake Form

First name

Last name

Phone

Has anything changed since your last facial appointment?

Did you notice improvements after your last session? If yes, please describe:

Did you experience any reactions, irritation, breakouts, or negative results?

Have there been any changes to your health, medications, supplements, or medical treatments?

Since your last visit, have you had any of the following?

Multi choice

Botox or filler (within 30–60 days)

Facial surgery or dental work (within 30 days):

Facial tattoos (within 30 days):

Cold sore (within 30 days):

Pregnant or given birth within the last 30–60 days

Are there any new areas of concern or goals you would like to focus on today?

Signature

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Date

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