Name *

Email address *

Have you received facials before?

Never

Occasionally

Regularly

How often?

Have you ever received a lymphatic facial or lymphatic drainage?

Yes

No

Do you have specific areas of concern?

Are there any areas to avoid?

Do you have any diagnosed or suspected skin conditions? If so, please list.

Do you have topical allergies or sensitivities? Please list.

Are you on birth control pills or hormones currently? If yes please list.

Are you currently taking any new medications? If yes please list.

Do you wear contact lenses?

Yes

No

Do you experience stress often?

Yes

No

Do you smoke?

Yes

No

Is your menstrual period occurring now or soon?

Yes

No

What is your daily water consumption?

Low

Moderate

High

What is your daily caffeine intake?

Low

Moderate

High

What is your daily intake of sugary or artificially sweetened drinks/food?

Low

Moderate

High

Are you using any of the following products?

Please list brand(s) if known.

Please check any of the following which apply to your skin:

Please indicate your primary reasons for receiving facials:

All facial services provided at Myo Massage are performed by massage therapists. Our focus is on relaxing the intricate muscles of expression and enhancing the lymphatic circulation to your skin. We use suki® products which are 100% natural & free of any synthetic ingredients or preservatives. Your facial will not include skin analysis or extractions. For complex skin concerns, please consult an aesthetician. *

I understand

Facial Preferences Form

The Myo Institute

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