Request Consultation

703-944-4791

Membership

Membership

Call us Now!

703-944-4791

Client Intake Form Prepaid

Menu

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

Menu

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

CONNECT WITH US

2915 Hunter Mill Rd, #22-23,
Oakton VA 22124

Phone: 703-944-4791

We accept CareCredit payment

Client Intake Form (Prepaid)

Please enable JavaScript in your browser to complete this form.

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? *

Describe *

Are you currently taking any medications? *

Describe *

Do you have any allergies? *

Describe *

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.

Are you at least 18 years old? *

Yes
No

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/ *

703-944-4791
2915 Hunter Mill Rd, #22-23, Oakton VA 22124

About Us
Gift Card
Services