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Treatment to be performed

Facial (may include dermal planing, high-frequency, dermal planing, light chemical peel, Light therapy)

Microchanneling

Chemical Peel

Microdermabrasion

Hydrofacial

First name(Required)

Last name(Required)

Phone number (enter 1 after the +)

Email(Required)

Birthday

Month

Day

Year

Address(Required)

Any known allergies?(Required)

Which of these scents would you prefer?

Peppermint

Lavender

Citrus

Eucalyptus

Blend

What is your stress level?

Low

Moderate

High

Skin Concerns(Required)

Acne

Blackheads

Broken Capillaries

Comedones

Eczema

Dryness/dull skin

Fine lines/wrinkles

Hyperpigmentation

Hypopigmentation

Milia

oily skin

Redness

Rosacea

sun damage

uneven texture

Other

Have you had any recent procedures done to your face/skin (chemical peels, collagen induction, waxing etc)

Yes

No

Emergency Contact Name (Required)

Relationship(Required)

Emergency contact phone number:(Required)

I confirm that I am 18 years old or over.

If you are making this appointment for a minor, you confirm that you are the legal guardian and will be present during the treatment.

Are you taking any medications that would cause excess bleeding, sensitivity or thinning of the skin? If so please list them. Type N/A if not applicable(Required)

Have you in the last 3 months taken Retinol-A, Renova, or Collagen injection? If yes, please explain.(Required)

Any surgeries you had recently or in the past? including plastic surgery that would affect your treatment?(Required)

Have you had any botox/fillers recently? If so, when?(Required)

Have you recently had any laser treatments/chemical peels recently? If so, when?(Required)

Have you had any wax done recently? If so when?(Required)

Do you have or have you had any of the following medical conditions? If yes, please explain(Required)

Acne

Arthritis

Blood disorder

Cancer/chemotherapy

Cardio/vascular issues

Diabetes

Depression

Easily bruised

Epilepsy/seizure

Fungal Infection

Heart Condition

Herpes

Keloid scarring

Loss of sensation

Low Blood pressure

Pregnant/breastfeeding

Thyroid condition

Warts

none of these

Other

please explain

Have you had any recent sun exposure or tanning that changed the color of your skin?(Required)

Are you currently on chemotherapy medications? Oral or IV medications? or Receiving radiation therapy? (Required)

Have you ever taken acne medication? If yes, when and which medication?(Required)

Do you smoke?(Required)

yes

no

Skin History: What is our skin type?(Required)

Normal

Oily

Dry

Combo

unsure

Are you pregnant or trying to get pregnant?(Required)

No

Yes

Skin Care: Do you currently use any of these products?(Required)

eye cream

cleanser

skin toner

moisturizer

exfoliants

SPF

Other

Your Exposure to the sun(Required)

Never - Light (0-1 hour a day)

Light (1-2 hours a day)

Moderate (2-3 hours a day)

Excessive >3 hours a day

How often do you wear make up(Required)

rarely

sometimes

always

How does your skin heal?(Required)

Fast, no scarring

slow

pigments

scars

Do you bruise easily?(Required)

yes

no

I confirm that I do not have any open skin lesions that would affect my facial treatment.

I grant permission to L Egance Esthetics to take photographs or videos of me, my likeness and my overall appearance duirng my visit/appointment. If so, all rights of photographs/video will belong to L Egance Esthetics and will only be for the sole purpose of education or marketing purposes.

I confirmed that I completed this form truthfully and to the best of my knowledge.

By signing below, I hereby release L Egance Esthetics Wellness and Beauty harmless from and waive on behalf of myself, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation.(Required)

Sign in the box or use the keyboard to type.

Signature field is empty.

LET'S GET IN TOUCH

Location

379 Kamehameha Hwy

Pearl City Hawaii, Hawaii

leganceesthetics9.com

email: leganceesthetics9@gmail.com

Instagram: readysetglow_9

Opening Hours

Thursdays 10am - 6 pm

Saturdays 10am - 6 pm

by appointment only

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Available online

Acne Treatment

1 hr 15 min • $85

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