Majestic Esthetics by Jabriell

Facial Intake Form

Welcome! Please complete this intake form so we can provide you with the best facial treatment experience.

First name

Last name

Email address

Phone number

Date of birth

Month

Day

Year

Skin Assessment

Please describe your current skincare routine

How often do you get professional facial treatments?

Please list any allergies or sensitivities

Current medications or supplements

Are you currently using any of the following?

Retinoids/Retinol

Prescription acne medications

Chemical peels or exfoliants

None of the above

How many glasses of water do you drink daily?

How much sun exposure do you get?

Minimal (mostly indoors)

Moderate (some outdoor activities)

High (work outdoors/frequent sun exposure)

I understand that results may vary and that multiple treatments may be needed to achieve desired results

I consent to facial treatment and photography for before/after documentation

Additional comments or questions