Cantik Esthetics

New Client Intake Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth
Phone Number*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about me?*

Website / Online SearchYelpFacebookReferralOtherOther
If Referral, please list name

Post-Care Instructions

Facial Care/Waxing
*Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. *Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitized to the sun as a result of this treatment. *POST Chemical Peel **DO NOT wash face for 48 hours Keep Dry.* Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. *Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity.* Consult your skin care professional before resuming topical treatments.*Enzyme , chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. Polysporin triple antibiotic ointment may be applied if needed. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results. Post care recommendations /skincare prescription are given to attain optimal results.*

I have read the post-care instructions and agree to adhere to them.
Post Thermo-Coagulation Care Instructions:For best results: Keep treatment area as dry as possible. Depending on size/are/anomalie treated, day 2-3 area may become/appear/feel slightly irritated (itchy) It is a part of the healing process.**DO NOT pick or scratch scabs. Scabs will form from anywhere day 5-7. The longer the scab stays on, the better. You may at this time apply recommended Moor Spa Soothing Lotion (purchase from me) or dab with certified organic coconut oil. That will help the scab not dry out and fall off too fast. It will nourish the new cells as they are regenerating underneath! Anomalies removed from the underarm or upper body, loose clothing is recommended for comfort. Healing time for this procedure is a full 28 days for cell turnover. Blemishes can sometimes take longer to heal, depending on skin type and post skincare home regimen. You will not scar. If a second treatment is needed, 4-6 weeks is recommended between each. Please contact Liza with any questions post treatment if needed.*

I have read and fully understand the above post-care for Thermo-Coagulation treatments. I am aware of the Disclaimer on the cantikesthetics.ca website. I understand that the optimal outcome of my results depend on my continued home-care instructions.
*I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. *I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.*

Yes
Signature*

Clear
Should be Empty:

New Client Intake Form

Your Skin

Your Health

Female Clients

Post-Care Instructions