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Facial Intake Form

Welcome to Beauty & Spa On The Go!

Our facials are designed for one-time special occasions, offering a luxurious and rejuvenating experience wherever you are. Please complete this form to help us customize your treatment for the best possible results.

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Service

MM slash DD slash YYYY

Location of Service(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have any known skin conditions (e.g., acne, rosacea, eczema, psoriasis)?(Required)

Yes

No

Please List(Required)

Do you have any allergies (including skincare products, essential oils, or latex)?(Required)

Yes

No

Please List(Required)

Have you had any recent facial treatments (e.g., chemical peels, microdermabrasion, laser treatments)?(Required)

Yes

No

Are you currently using any of the following skincare products?(Required)

Retinol/Retinoids

Alpha Hydroxy Acids (AHAs)

Beta Hydroxy Acids (BHAs)

Prescription Acne or Anti-Aging Medications

None

Do you have sensitive skin or experience irritation easily?(Required)

Yes

No

Do you have any open cuts, wounds, or active cold sores?(Required)

Yes

No

Are you pregnant or nursing?(Required)

Yes

No

Do you have any other health conditions we should be aware of?(Required)

Yes

No

Please List(Required)

I understand that Beauty & Spa On The Go provides one-time facials for special occasions and not ongoing skincare treatments.
I acknowledge that I have disclosed all relevant medical and skin conditions and that Beauty & Spa On The Go is not responsible for any adverse reactions. I understand that results may vary based on my skin type and condition.
I release Beauty & Spa On The Go and its staff from any liability related to my facial treatment.

Consent(Required)

I agree

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Contact Info

Palm Springs, California
Call or Text: (760) 620-3287
[email protected]

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