Intake form - Dianas Earth Skincare

Please take a moment to carefully read and complete this form. Sign where indicated. Please dress comfortably for your treatment, as you will NOT be changing into a gown. Joggers and tanks exposing decolate and shoulders are preferred. Looking forward to meeting you 🙂 .

Please Upload A Picture Of Yourself Closeup *

Client's First Name*

Client's Last Name*

Mother's Name (If A Minor)

Age of Client*

Email Address*

Phone*

Street Address*

Apartment, suite, etc

City*

State/Province*

ZIP / Postal Code*

Do You Need Help With A Skincare Routine? * Yes
No

How Did You Hear About Me? * Facebook Group
Google
Friend/Relative
Other

What Are Your Specific Concerns/Challenges With Your Skin? How Long Have You Been Struggling With These Concerns/Challenges? Be Specific On What You Hope To Achieve From Your Treatment
Today*

Do You Have Dental Implants, A Pacemaker Or Body Piercings? * Yes
No

Do You Have Any Allergies, Including Foods, Skin Products Or Ingredients, Animals, Etc.? * Yes
No

List Any And All Prescription Meds, Oral And Topical That You Use Or Have Used In The Past Year (Trentinoin, Lipitor, Etc) *

Have You Had Any Dermaplaning, Microneedling, Botox, Injectables, Dermal Fillers Or Any Other Advanced Facial Or Cosmetic Treatments Within The Last Month? * Yes
No

Have You Ever/Are You Currently Using Accutane® (Acne Medication)? * Yes
No

Have You Had Any Chemical Peels, Microdermabrasion Or Any Resurfacing Treatments Within The Last Month? * Yes
No

Please Specify If Any Of The Following Apply To You: * Pregnant
Trying To Become Pregnant
Lactating
Menstruating
Pre-Menstrual
Premenopase
Premenopase
N/A

Have You Been Waxed Or Shaved Your Face Within The Last 72 Hours? * Yes
No

What Do U LIKE In A Treatment? This Is Not To Say You Will Get It All, Depending On Time And Skin Condition. It's A Way For Me To Get To Know What You Like. Bed Warmer On
Don't Talk To Me
Talk To Me, I Like To Know What Is Being Done At Every Step
I Love Hot Steam!
No Steam
Minimal Squeezing
Music With No Words
Music With Words, I Like To Sing Along!

I Give My Permission For Diana Aka Diana's Earth To Post Any Videos Or Photos Of Services Performed On Me And Any Information Regarding The Services That I Have Received To Its Social Media Sites Including Its Website, Instagram, YouTube, Facebook And Tik Tok. * Yes
No

2023 Consent *

By Signing Below I Certify That I Have Answered The Questions To The Best Of My Knowledge And Will Inform Diana Of Any Changes To This Form Going Forward For The Calendar Year 2023. A Copy Of My Responses Will Be Sent To My Inbox That I Can Reference For Future Appointments. For Minors, A Parent Will Need To Sign.

Type Your Name In Box And It Will Serve As A Legally Binding E-Signature