Makeup Intake Form

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First Name

Last Name

Date of Birth

Phone

Address

How did you hear about us? *

Precise Beauty Bar Website

Instagram

Facebook

Yelp

Google

Referral

If Referral, please list name:

Have you used any chemical exfoliants (AHAs/BHAs) in the past week? *

Yes

Are you using any retinol such as Retin-A, Renova, Tretinoin or Accutane? *

Yes

Are you using any other skin thinning, brightening products or medications? *

Yes

Have you had any reaction or have allegies to any cosmetic skincare products? *

Yes

If yes, please specify:

Have you had chemical peels, laser or microdermabrasion treatments in the last month? *

Yes

Do you have any special skin concerns pertaining to your face or body? *

Yes

If yes, please specify:

Skin Conditions

Sensitive

Papules

Dehydrated

Mature/Aging

Dark Circles

Hyperpigmentation

Acne

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 skin care professional and business from liability and assume full responsibility thereof. *

Your Signature

Date

Thanks for submitting!

info@precisebeautybar.com

18885037910

3500 Chateau Blvd. Suite 206
Kenner, LA 70065

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