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Oxygeneo Facial

Please fill out the following form
in order to participate in our service.

First name

Last name

Date Of Appointment

Have you had a facial before?

Yes

No

Did you have any trouble with previous facials? *

Yes

No

What are your specific skincare concerns you would like the Oxygeneo to help with?*

Dry skin

Wrinkles

Acne

Skin Texture

Redness

Breakouts

Blackouts

Large Pores

Skin Sensitivity

Oily Skin

Any known allergies?

Fruits

Shellfish

Latex

Dairy

Wheat

Tree nuts

Lidocane

Fragrance

Pollen

Are you on Accutane?

Yes (Please note treatment can't be done)

No

Are you on birth control?

Yes

No

I hereby agree to have this treatment. I am aware that even with natural ingredients there is a rare chance of a reaction (skin redness, swelling) and there is a possibility of an adverse reaction to product used in facials. I am also aware that certain services should not be performed with certain medical conditions or prescriptions. I have disclosed to the staff at Glitz Spray Tanning all my known medical conditions, skin conditions, allergies, medications and answered all questions honestly on the above form. It is my responsibiliy to disclose all medical, and skin history, as Glitz Spray Tanning will not be responsible to reactions caused by undisclosed medical history. I understand everyones result vary. By signing below, I confirm that I have read and understand the above information and agree to undergo the treatment.

Initials