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New Client Skin Care

Name *

First

Last

Date & Time of your appointment *

Example: 09/29/2022 at 12:00pm

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Have you ever had a facial before? *

If yes, how was your experience. If no is there a reason you have never had a facial? *

How would you best describe your skin | Check all that apply *

Normal (no breakouts & no real issues)
Dry
Oily
Combination of Dry in some parts and oily in others
Acneic Low Level (breakouts but isn't too bad)
Acneic High Level (breakouts are very bad and painful)
Mature with fine lines and wrinkles

Why did you decide to come in for a facial? *

What results are you hoping for? *

Check all massage places that are NOT OK to massage during your facial *

Neck/shoulders
Arms/Hand
Feet
Hair/Head
All listed above are ok by me and understand you will ask me again before the service starts.

Most facials incorporate relaxing massage at various stages of the service to enhance health benefits moving & oxygenating the blood with movement. It is top priority to make sure you are comfortable and you enjoy your experience so if there is a place you DO NOT WANT massaged whether due to injury or discomfort please check any of the boxes above. If all are ok then choose the last box approving areas for the massage.

What is your current face routine? *

Please include products that you use, time of day that you use them and anything else that you can think of. The more I know the better off I can help guide you on your skin journey

Is there anything else you think I should know before your facial? *

The more open and honest you are the better I will be able to serve you as an esthetician. This is your chance to ask questions. State concerns or anything else that pops into your head to ask before you come in.

@belljaxsalon

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3300 bonita beach rd sw #106
suite #16
bonita springs, fl 34134

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Phone: ‭(239) 970-4907‬

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