Referred By (check all that apply):

3. Which conditions would you like to improve? (Check all that apply)

4. Have you ever had facial treatment in the past?

6. How would you describe your skin?

7. How would you rate your skin? (Fitzpatrick Scale)

8. Do you ever experience any of the following? (Check all that apply)

10. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?

I fully understand all questions above and have answered them correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will inform me of what to expect in the course of treatment and may recommend adjustments if deemed necessary. I agree to actively participate in following appointment schedules and home care procedures to achieve maximum effectiveness.

I release and hold harmless Marble Skin and its staff from any liability for adverse reactions that may result from this treatment.

Cancellation Policy: We require 48-hours notice for cancellations. Cancellation for Monday must be phoned in on the Friday before.

Product/Service Policy: If you are not satisfied with your service or products, please contact us within 24-hours after your appointment so that the situation may be corrected.