APPOINTMENTS

LILAC & DAHLIA

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APPOINTMENTS
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HOME
ABOUT
SERVICES
- FACIALS
- WAXING
APPOINTMENTS
GIFT CERTIFICATES
CONTACT
SHOP

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YOUR CART

Prior to any facial services, clients must complete the intake form below. You may also complete the form in person on the day of your appointment.

Waxing services require a signed consent at time of service. If you are booking a wax there is no need to fill out the form below.

INTAKE FORM

* Indicates required field

First & Last Name *

First

Last

E-mail *

Phone Number *

Birthdate *

Emergency contact name and phone number *

Referred By *

This is my first facial *

Yes No

If no, when was your last facial? *

Briefly describe you skincare routine *

What are your facial goals? *

Are you interested in product recommendations? *

Yes No

Are you under a physician’s care for any current skin condition? *

Yes No

If yes, please explain. *

Please list any allergies to skincare ingredients, food or drugs. *

Please list all topical medications, oral medications and/or supplements you take. *

Please select any that apply to you *

Do you currently smoke? Do you have any metal implants? Do you wear contacts? In the last two weeks have you received any injectables? Do you currently use any RX strength Vitamin A (Retinoids)? Do you wear Sunscreen? Are you currently breastfeeding?

Are you currently pregnant? *

Yes No No, but trying.

Are there any medical conditions I should know about? *

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full
disclosure, and that it supersedes any previous verbal or written disclosures. I understand that
withholding information or providing misinformation may result in contraindications and/or
irritation to the skin from treatments received. The treatments I receive here are voluntary
and I release this institution and/or skin care professional from liability and assume full
responsibility thereof.

Initial *

Date *

SUBMIT

L I L A C & D A H L I A

207 16TH STREET
SUITE 208
PACIFIC GROVE, CA
93950