Experience Facial Ritual- Intake Form

First name

Last name

Email

Phone

WHAT IS YOUR AGE RANGE?

0-20

21-39

40-50

60+

WHY ARE YOU INTERESTED IN THE EXPERIENCE FACIAL RITUAL AT THIS TIME AND WHAT ARE YOU HOPING TO ACHIEVE FROM OUR TIME TOGETHER? (physically, emotionally, spiritually or other)

DO YOU FEEL ANY ENERGY STUCK OR ANY STAGNATION IN YOUR BODY? IF YES, WHERE?

YOUR INFRADIAN RHYTHM: a 28-31 day cycle that regulates the menstrual cycle. ARE YOU AWARE OF WHICH PART OF YOUR MOON CYCLE YOU ARE IN AT THE TIME OF YOUR SERVICE? (this will allow me to prepare your herbal blends to support what your body is needing)

MENSTRUATION ( the 1 - 7 days of your period)

FOLLICULAR (the 7 to 10 days after your period)

OVULATORY (the to 4 days in the middle of your cycle)

LUTEAL (the 10 to 14 days between ovulation and your period)

NO LONGER (pregnancy/ historectomy / menopause / other)

HOW WOULD YOU DESCRIBE YOUR CURRENT STRESS LEVELS? NONE/LOW/MEDIUM/HIGH

DO YOUR SUFFER FROM ANY KNOWN ALLERGIES? (environmental, topical, food)

HAVE YOU HAD ANY MEDICAL CONCERNS THAT I SHOULD BE AWARE OF? (including the use of retinoid medications, heart conditons, cancer, autoimmune disorders, major surgery)

WHICH FACIAL PRODUCTS ARE YOU CURRENTLY USING AS A PART OF YOUR SKINCARE ROUTINE?

HOW DID YOU HEAR ABOUT NORTHERN ALKEMI BEAUTY?

DO YOU GIVE PERMISSION FOR PICTURES & VIDEOS FOR THE PURPOSE OF DOCUMENTATION, POTENTIAL ADVERTISING AND PROMOTIONAL PURPOSES?

YOUR SATISFACTION AND SAFETY IS MY NUMBER ONE PRIORITY TO ENSURE YOUR WELLBEING BEFORE, DURING AND AFTER YOUR TREATMENT. PLEASE BE AWARE OF THE FOLLOWING INFORMATION AND CHECK MARK BELOW

I’ve shared all relevant details about my health history, including any medications I’m currently taking and any past reactions to products or medications that might affect or interfere with this treatment.

I understand that there may be other factors that could affect how well I tolerate the treatment. I’m also aware that there are some risks involved, and in very rare cases, I might experience skin irritation or discomfort.

By proceeding, you confirm that you fully understand the service you’ve requested and the associated risks. You’ve shared any relevant pre-existing conditions, allergies, or sensitivities with your service provider. Northern Alkemi Beauty and the service provider are not responsible for any dissatisfaction, discomfort, injury, or damage that may occur as a result of the service.

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