Skip to content
Mon. - Fri., 9.00 am-5.00 pm (appointments only)
Address : 12004 Carmel Mountain Rd suite 48, San Diego, CA 92128, United States
Home
About
Google Reviews
Services
Contact
Shop
Intake Form
Book Now
Home
About
About Us
Google Reviews
Services
Contact
Intake Form
Book Now
Shop
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Customer Details
activity? follow I
Full Name
*
First
Last
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Phone Number
*
Email
*
How did you hear about us?
Nextdoor
Google
Friends or family
Social Media
Other
Do you have any allergies or health concerns we should know about?
*
Yes
No
Please explain more about them
*
Are you pregnant or breastfeeding?
*
Yes
No
Do you have any pain in any part of your body that can effect your daily activity?
*
Yes
No
Please explain shortly
*
Which service are you interested for today or future?(Choose as many as you are interested)
Microcurrent facial treatment
Product recommendation
Microdermabrasion
Hydrodermabrasion
Ultrasonic facial
Facial infusion (micro-channeling)
Not sure
How would you describe your skin or your biggest concerns?
Acne/Acne Scaring
Hyper pigmentation/Sun spots
Third Choice
Aging/Fine lines
Rough Texture/Not smooth
Dry/Flaky Skin
Irritation/Sensitive/Redness
Want to prevent aging
Large Pores/Oily
Not sure
Are you on any of these medication?
*
Accutane/Isotrention
Antibiotics
Clindamycin
Trentinoin
Zerac
Fosdex
Renova
DesquamZ
Cortisone
Retin-A
Differin
Avage
Other
Non of the above
Please tell us more about that
*
Have you been waxed or threaded on your face in the last 7 days?
*
Yes
No
What does your skincare regimen look like?
Cleanse
Exfoliate with scrub or chemical
Tone
Mask
Moisterizer
SPf
Eye Cream
Are you consistent with your skin home care?
Yes
No
Have you ever had any of these treatment in the past?
Facial
Chemical Peel
Microneedling
Hydra Facial
DermaPlaining
IPL/Laser
Never had anything done
Were you ever treated for skin condition from your dermatologist ?
*
Yes
No
Please explain shortly and did you like the results?
*
I consent to perform skin treatments on myself. I understand I will follow all post treatment care and follow directions. I will make sure to contact Sara Jahromi with any questions and make sure I am truthful with my intake form. I agree that I am not on any medications that could potentially be a contraindication.
*
Yes
No
I understand and accept that any skin treatments may have risks and reactions, as individual skin types can vary in response.
*
Yes
No
I agreed to take a picture of my face and skin to be shared on social media
*
Yes
No
OUR POLICIES: We kindly ask that you allow at least 48 hours notice to avoid a cancellation fee. We will charge 50% of the scheduled service. All services require a credit card at the time of booking.
*
I read and agreed to Skinbeautyq cancelation policy
Signature
*
Clear Signature
Submit
