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Client Intake Form
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FAQs

About Us
Gift Card
Services
Payment Plans
Monthly Specials
Contact Us
Client Intake Form
- Client Intake Form (Prepaid)
FAQs

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2915 Hunter Mill Rd, #22
Oakton VA 22124

Phone: 703-944-4791

We accept CareCredit payment

Client Intake Form

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Treatment *

Name *

First

Last

Referred By

Address *

State *

Zip Code *

Date of Birth *

Phone Number *

Mobile Number *

Emergency Contact Name *

Emergency Contact Mobile Number *

Email *

How often do you have facial done? *

Have you ever had a reaction to a facial? *

If yes please describe here

Are you currently taking any medications? *

If yes please describe here

Do you have any allergies? *

If yes please describe here

Please select your skin type *

Dry
Oily
Normal
Acne
Other

Describe your skin *

What are you hoping to achieve or get from today’s facial/treatment? *

Which skin products are you using? *

Please select any health condition(s) that applies *

Please list any other health issues not listed above *

Purpose of skin products used *

Are you currently using any of the following *

Consent *

I have elected by my own decision, to have facial / treatment done.
I have read and understood the above information and have given accurate answers to the questions.
I give the Esthetician permission to perform the facial procedure / treatment.
I understand that there are often inherent risks associated with skin care services, and I agree that as a condition for providing this service, I hold this facility, and Esthetician harmless from any problem that may result from this treatment.
I acknowledge that I have received, reviewed, and fully read the Treatment Plan Informed Consent for my procedure ( Laser Treatment / Morpheus8 / Skin Tag Removal ) and all related documentation in full prior to treatment.

I understand the nature of the procedure, including its risks, benefits, limitations, alternatives, and that results may vary based on individual biological or hormonal factors.

I understand that the number of sessions required may vary and that no specific number of sessions has been guaranteed.

I confirm that no other guarantees, warranties, or representations regarding outcomes have been made, and I am not relying on any statements outside of the written consent.

I have had the opportunity to ask questions, all of which have been answered to my satisfaction. I voluntarily elect to proceed with treatment, knowingly assume all inherent and disclosed risks, and understand that this electronic acknowledgment is legally binding and equivalent to a handwritten signature.

Are you at least 18 years old? *

Name *

Kindly type your full name between two forward slashes “/” such as /About Image Med Spa/ *

I (Parent/Guardian's Name) *

Authorize treatment on (client’s name) *

Kindly type your full name between two forward slashes “/” such as /About Image Med Spa/ *

$25.00

Appointment Confirmation Deposit/Promotion Booking.
Cancel/reschedule 24 hours before appointment, otherwise deposit will be forfeited.
To be respectful of everyone’s time, arriving late may result in a shortened appointment.

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703-944-4791
2915 Hunter Mill Rd, #22, Oakton VA 22124

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