New Client Intake Form
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Name
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Phone Number
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Your Skin
What are your skin care goals?
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What are your skin care challenges?
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Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Aging
Acne / Acne Scarring
Redness / Rosacea
Melasma
Sensitivity
Other
Please feel free to go into more detail
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
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Yes, within the last month
Yes, within the last 2-3 months
No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
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Yes
No
What Skin Care Products do you currently use? (Click all that apply)
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Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
OPTIONAL - Upload a photo of the products that you are using.
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This is completely optional, but if you are seeking corrective treatments we can use this photo to help you meet your skin care goals based on the specific products you are currently using.
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How did you hear about me?
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Website / Online Search
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Referral
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Post-Treatment Care Instructions
Please follow these guidelines carefully to support proper healing and achieve the best results from your treatment.
Facial Care and/or Waxing Instructions: Avoid aerobic exercise and vigorous physical activity for 48 hours following treatment. Direct sun exposure—including tanning beds and strong UV light—should be avoided immediately afterward; if exposure is unavoidable, apply a broad-spectrum sunscreen with SPF 30 or higher. To protect your skin long-term, incorporate a daily sunscreen with a minimum SPF 15 into your skincare routine, as the skin may become more sensitive to sunlight. After a chemical peel, do not wash your face or allow it to get wet for 48 hours unless otherwise instructed. On the evening of your treatment, gently cleanse with a mild cleanser and water, then apply a non-active moisturizer. Do not use exfoliating products or ingredients on the day of treatment, as over-exfoliation may cause irritation or sensitivity. Consult your skincare professional before resuming any topical treatments. Enzyme or chemical peels and facial waxing may result in temporary redness, mild flaking, or sensitivity for up to 48–72 hours; Polysporin Triple Antibiotic Ointment may be used if needed. Do not peel, pick, rub, or scratch the skin at any time, as this can cause damage or compromise your results. Adhering to the recommended post-care regimen and prescribed skincare will help ensure the best possible outcome.
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I have read and understand the post-care instructions, and I agree to follow them as recommended.
Post Thermo-Coagulation Care Instructions: For best results, keep the treated area as dry as possible. Depending on the size, location, and type of anomaly treated, the area may appear or feel slightly irritated or itchy around days 2–3—this is a normal part of the healing process. Do not pick or scratch any scabs. Scabbing typically begins around days 5–7, and the longer the scab remains in place, the better the outcome. At this stage, you may apply the recommended Moor Spa Soothing Lotion (available for purchase from me) or gently dab the area with certified organic coconut oil to keep the scab from drying out and falling off prematurely. These products help nourish the regenerating skin underneath. For anomalies treated in the underarm or upper body area, wearing loose-fitting clothing is recommended for comfort. Full healing typically takes 28 days to allow for complete cell turnover; however, blemishes may take longer to heal depending on your skin type and home care routine. Scarring is not expected. If a second treatment is needed, please allow 4–6 weeks between sessions. For any post-treatment questions or concerns, feel free to contact Liza directly.
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I have read and fully understand the post-care instructions for Thermo-Coagulation treatments. I acknowledge the disclaimer available on cantikesthetics.ca and understand that optimal results depend on my adherence to the recommended home-care regimen.
I have read, understood, and completed this questionnaire truthfully. I acknowledge that this constitutes full disclosure and overrides any prior verbal or written information provided. I understand that withholding or misrepresenting information may lead to contraindications or adverse reactions to treatments received. I acknowledge that all treatments are voluntary, and I release the skincare professional from liability, assuming full responsibility for any outcomes.
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I agree to the above statement and confirm that the information I have provided is accurate.
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