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Facial Client Intake Form

All information is confidential. You will be charged a $35 deposit upon submitting this form. Once received, I will reach out to you to set up your appointment. Thank you!

Birthday
Year
Month
Day
Which Facial would you like to book?

Health & Skin History

How would you describe your skin type?
Dry
Oily
Combination
Normal
Sensitive
Unsure
Are you currently using:
Are you pregnant, nursing, or trying to conceive?
Yes
No
Have you had any cosmetic procedures (Botox, fillers, peels, laser, etc.) in the last 3 months?
Yes
No
How would you describe your stress level?
Low
Moderate
High

Lifestyle and Wellness

Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you exercise regularly?
Yes
No

Client Disclaimer & Consent

I understand that the facial treatments provided by The Dharma Den is intended to improve the appearance and health of the skin using natural and holistic methods.


I acknowledge that:

  • All products used are natural and or artisan-made, but may still cause individual reactions or sensitivities.

  • Crystal Veenstra is not a medical doctor and does not diagnose, prescribe, or treat medical conditions.

  • Results vary depending on skin type, lifestyle, and aftercare.

  • Certain treatments (such as microdermabrasion, facial cupping, or electrical tools like PureLift Pro) may cause temporary redness, minor bruising, or sensitivity.

  • It is my responsibility to inform Crystal of any changes in my health, skin condition, or medications before each session.

  • I release the practitioner from any liability related to my treatment experience.


By signing this form, I consent to receiving holistic facial treatments and understand that my information will remain confidential and used only for treatment purposes.

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Date
Year
Month
Day
Deposit
$35
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