First Name
Last Name
Phone
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Email
My reason for being here:
(check all that apply)
Aromatherapy - Some facials may include aroma-therapeutic essential oils and essences if you wish. Which are your favorites?
(check all that apply)
Any allergies?
(check all that apply)
Share more about your allergy if you have one. Is it a topical allergy? An internal allergy? What type of reaction does it cause?
Any prescription drugs, supplements or herbal remedies that could affect your skin?
Any medical conditions that could affect your skin or influence what the best treatment/facial for you will be?
Have you had any medical cosmetic treatments?
check all that apply
Anything else you'd like to share about your skin or you?
Your vibrant, gorgeous, health skin for life is our goal! With that in mind, please note the following: If my purpose for receiving treatments/facials is to improve the health and appearance of my skin, I agree to follow both the home care protocols and facial/treatment schedule outlined for me by my Rich Earth Organic Skin Care Studio practitioner. If I experience an unexpected reaction to a facial/treatment or to a recommended skin care product, or have any questions about my prescribed home care regimen, I will contact Rich Earth Organic Skin Care Studio expediently for guidance.
All of the above information is true and accurate to the best of my knowledge. I will inform Rich Earth Skin Care Studio if any of the information I have provided changes.
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