New Client Intake Form
Element Skin Therapy
Name
*
First Name
Last Name
Birth Date
*
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Email
*
For appointment reminders, follow-ups, etc.
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Website / Online Search
Social Media
Referral
Other
If referral, please list name
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Are you allergic to anything?
*
Yes
No
Please list your allergies
Are you currently pregnant or breastfeeding?
*
Yes
No
Are you currently taking any medications or supplements?
*
Yes
No
Do you have a pacemaker or facial metal implants?
*
Yes
No
Please list all medications/supplements
Have you ever had a facial or skin treatment before?
*
Yes
No
If yes, when?
Do you have any medical conditions or take medications that impact your ability to receive a facial and/or waxing treatment?
*
Yes
No
If yes, what condition(s)/medication(s)?
Do you have any medical conditions or take medications that recommend you avoid certain skincare ingredients?
*
Yes
No
If yes, what ingredients should you avoid?
Have you been under the care of a dermatologist?
*
Yes
No
If yes, please provide more information
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What conditions would you like to improve?
*
Acne
Oily Skin
Dry Skin
Bumps
Large Pores
Melasma
Redness
Brown Spots
Sun Damage
Milia
Sagging Skin
Rosacea
Lines & Wrinkles
Healthy Aging
Age Management
Scarring
Keratosis Pilaris
Hyperpigmentation
Other
What are your skin care goals?
What skin care products do you currently use?
Check if you are using a product
Brand Name
Product Name
Any thoughts?
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
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Next
By clicking these boxes I agree to the following:
*
I have read and agree to Element Skin Therapy’s policies, including the cancellation policy, as listed here: https://www.elementskintherapy.com/our-policies and understand the prices are subject to change
I consent to "before and after" photos and videos for the purpose of documentation, social media, potential advertising, and promotional purposes. Before and after photos are a huge part of how we attract amazing clients like yourself! I understand that photo documentation is necessary to gauge progress and reactions, however releasing Element Skin Therapy and its practitioners to publish these outside of the practice is optional. I understand that I can retract authorization to release photos/videos outside of the practice via written request. This retraction will apply to any future use of photos/videos for advertising, promotional, or other purposes.
*
I allow Element Skin Therapy to use photos/videos for documentation, promotional, and/or advertising purposes.
I allow Element Skin Therapy to use photos/videos for documentation only.
*
If waxing, I agree to discontinue the use of retinols, glycolic acids, salicylic acids, physical, or other chemical exfoliants at least 48 hours before the service. While uncommon, I understand that bruises, scabs, scarring, redness, hyperpigmentation, pimples, or flare ups can be a side effect of any type of waxing. I will notify my practitioner of any changes in my skin care routine or medications prior to the service.
*
I understand, have read, and completed this form truthfully and accurately. I authorize Element Skin Therapy and its practitioners to perform the treatment I have selected and future treatments I select. This form applies to my current and all future appointments I have with Element Skin Therapy. I confirm that I do not have any existing medical conditions that may affect my treatment. I will notify my practitioner of any changes to my skin care routine or medications prior to every appointment. I authorize the use of topical skincare products, and other liquids, creams, ointments, etc. required for my treatment. I agree that treatments I receive are voluntary and I understand the risks and hazards associated and assume full responsibility thereof. I confirm that there is no guarantee for the treatment results and I agree to follow post-treatment home care according to the practitioner. I release Element Skin Therapy and its practitioners/employees for any responsibility in case of an accident, illness, or injury.
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