Facial Client Intake · Revival Beauty Co.

Full Name *

Phone Number *

Date of Birth

How did you hear about us?

Allergies or Medical Conditions *

Include skin conditions, allergies, medications, or anything we should know

I am currently pregnant or nursing

Some treatments may not be suitable during pregnancy

Please list any skincare you are currently using, including brands *

What Are Your Skin Concerns, If Any? How do you feel about your current skincare lineup? *

Have you had a facial treatment before? If so, when was your last one? *

Would you like a scalp massage during your mask portion of the service? *

Would you like to be told what I am doing/using during your treatment, or do you prefer a silent experience?

Photo & Social Media Consent *

May we photograph your results and share them on our social media or website?

Additional Notes

Client Signature *

Sign here

By signing, you acknowledge the information above is accurate