Lunar Energy Esthetics Intake Form

Please fill out the following information that applies to the appointment you have booked to the best of your ability.

First name

Last name

Email

Phone

Birthday

Address

Today's Date

Yes, subscribe me to your newsletter.

Your reason for booking

I give permission for Lunar Energy Esthetics to post any videos or photos of services performed on me and any related descriptive information obtained on me to it's social media sites including it's website, Instagram, Facebook, YouTube, or TikTok

Please only fill out the following sections of the type of service(s) you wish to receive

*SKIN

Is this your first facial

yes

no

Are you currently under a physician's care for any current skin condition?

yes

no

Have you had a chemical peel, microdermabrasion, laser, or dermaplaning treatment in the last 6 months?

yes

no

If yes, which one(s)

Do you sunbathe or use tanning beds?

yes

no

Are you pregnant or lactating

yes

no

Have you taken accutane or used Retin-A products or any topical prescriptions within the last 12 months?

yes

no

Have you had skin cancer?

yes

no

Do you smoke?

yes

no

How many glasses of water do you drink in a day?

Do you have any neck or should pain?

yes today

sometimes

no

Which skin concerns do you have?

What is your current skincare routine

Name any allergies/sensitivities you've had

Please check if you have been affected by or have any of the following

Please upload any photos or videos of your skin you have to help us create the best treatment plan for your skin goals

*LASHES

Lash Extensions

I agree to have eyelash extensions applied to my natural eyelashes and/or removed and reattached. By signing this, I consent to the placement and/or removal of the eyelash extensions by the certified eyelash extension professional listed below.

I understand and agree to the aftercare instructions provided by the certified eyelash extension professional for the use and care of my eyelash extensions.

I understand that if I request application of eyelash extensions beyond the recommended application advice of the certified eyelash extension professional I do so at my own risk. I realize and accept the consequences of failure to adhere to these instructions may cause damage to my own natural lashes and cause the eyelash extensions to fall out and/or decrease the time the eyelash extensions will last.

I understand and consent to having my eyes closed and covered for the duration of the application which can take 1-4 hours. Times may vary depending on the type and number of eyelashes applied.

I understand that in rare occasions there are risks associated with having artificial eyelash extensions applied to or removed from my natural lashes. I further understand that in rare cases part of the procedure or after application or soon after eye irritation and discomfort may occur.

I further understand that in rare cases part of the procedure or after application or soon after eye irritation and discomfort may occur. I agree if I experience any of these conditions with my lashes that I will contact the certified eyelash extension professional that preformed this procedure and that it may be necessary to have the eyelash extensions removed.

Please check off all that applies to you

Current use of contact lenses

Current use of oil containing skincare products including SPF and Makeup

Eye drops of any kind

History of recurrent eye or tear duct infections

History of dry eyes or Sjorgen's syndrome

Recent history of chemotherapy

Please list any other medical conditions, if applicable, which would inhibit or compromise placement and retention of eyelash extensions:

I agree to the following eyelash extension follow up maintenance instructions:

No waterproof mascara

No oil based products applied around the eye area

No pulling, rubbing or picking of the eyelash extensions

No mechanical type eyelash curlers used on the eyelash extensions

No picking or removing eyelash extensions myself

If I am pregnant, I have consulted my physician before having this procedure

Should any kind of eye drops be necessary extra care should be taken to prevent any moisture from coming into contact with the eyelash extensions

I will keep my eyelash extensions clean with eyelash cleanser and brush everyday

I understand that many factors such as lifestyle and environment are involved in eyelash extension retention and there is no guarantee length of time for the eyelash extensions to remain on

I have read and fully understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of & consent to this agreement and to the eyelash extension application procedures.

Lash & Brow Lift, Tint

What kind of service are you receiving?

Lash Lift

Brow Lamination

Tinting

Multiple

Is this your first time receiving a lamination/tint?

yes

no

Have you ever had an adverse reaction to this service in the past? Explain

Are you currently using Retin-A skincare products?

yes

no

Please check off all that applies to you

Current use of contact lenses

Current use of oil containing skincare products including SPF and Makeup

Eye drops of any kind

History of recurrent eye or tear duct infections

History of dry eyes or Sjorgen's syndrome

Recent history of chemotherapy

Are there any medical diseases, allergies or conditions/skin conditions we should be aware of?

I have read and fully understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I am over 18 years of & consent to this agreement and to the eyelash extension application procedures.

*WAXING

Have you had professional waxing done in the past?

yes

no

Have you had adverse reactions to waxing in the past?

yes

no

Have you used Retin-A, Accutane or active ingredient products on the part of the body we are waxing in the past 10 months?

yes

no

Do you have any chronic skin conditions that may compromise the skin barrier?

yes

no

If yes, please specify

Are you taking antibiotics, birth control or hormone replacements?

yes

no

Do you have any allergies including allergies to wax or latex?

yes

no

Have you used a tanning bed or experienced prolonged sun exposure in the past 48 hours?

yes

no

Do you have rosacea, eczema, psoriasis, cracked or open skin, severe varicose veins or any skin sensitivities?

yes

no

Please note waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the above information and have answered the questions to the best of my ability. If i have any concerns I will address these with my esthetician. I will hold my esthetician harmless from any liability that may result from this treatment.

Thank you for taking the time to fill out this intake form for your following appointment. If there are any concerns or questions we have, we will reach out via phone or email shortly.

Get ready to glow!

-Chantal

Lunar Energy Esthetics

Lunar Energy Esthetics Intake Form

Please only fill out the following sections of the type of service(s) you wish to receive

Using quality products from the following brands;

Follow @lunarenergyesthetics

Join the Lunar Community!

Lunar Energy Esthetics Intake Form

*Please only fill out the following sections of the type of service(s) you wish to receive*

Using quality products from the following brands;

Follow @lunarenergyesthetics

Join the Lunar Community!

Please only fill out the following sections of the type of service(s) you wish to receive