Signature Ritual Facial Intake Form

First name

Last name

Phone

Emergency Contact Name & Phone

Relationship

What are your skin goals and areas of concern?

How would you describe your skin? (Dry, Oily, Combination, Changes Seasonally):

Have you had a facial before? If yes, when and what type?

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?

Are you pregnant, trying, perimenopausal, menopausal, or experiencing hot flashes?

Are you currently under any medical treatments (such as chemotherapy, radiation, or anything that may cause skin sensitivity)? Please explain:

Thyroid issues?

Claustrophobia?

Do you experience TMJ or jaw pain?

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

Allergies

Contact lenses?

Hair extensions?

Photo & Media Consent

Do you give permission for before/after or during-treatment photos or videos to be taken and used?

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