Have you ever received a facial?*
- Yes
- No
Were you happy with the treatment?*
- Yes
- No
Why were you happy or unhappy with your treatment?
What would you like to change about your skin?
Have you received a deep skin peel in the past 2 months?*
- Yes
- No
Have you used retinol or glycolic acid in the past 72 hours?*
- Yes
- No
Skin Shaman will not treat individuals:
- that have used retinol or glycolic in the past 72 hours
- that have used Accutane within the past 12 months
- with active cold sores

Client Agreement
- Any information provided by Skin Shaman is for educational purposes only, and is not a substitute for medical diagnosis or treatment.
- All information provided by the client on this form is confidential.
- Compliance with all pre and post treatment protocols recommended by Skin Shaman is required to achieve the best results from your skin care treatments.
- All appointments require a minimum of 24 hour cancellation notice or are subject to a charge of 50% of the total cancelled service cost.
by checking here you accept the terms of the client agreement.

Client Intake Form

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