New Client Intake Form
Element Skin Therapy
For appointment reminders, follow-ups, etc.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
How did you hear about us?
Website / Online Search
If referral, please list name
Are you allergic to anything?
Please list your allergies
Are you currently pregnant or breastfeeding?
Are you currently taking any medications or supplements?
Do you have a pacemaker or facial metal implants?
Please list all medications/supplements
Have you ever had a facial or skin treatment before?
If yes, when?
Do you have any medical conditions or take medications that impact your ability to receive a facial and/or waxing treatment?
If yes, what condition(s)/medication(s)?
Do you have any medical conditions or take medications that recommend you avoid certain skincare ingredients?
If yes, what ingredients should you avoid?
Have you been under the care of a detmatologist?
If yes, please provide more information
What conditions would you like to improve?
Lines & Wrinkles
What are your skin care goals?
What skin care products do you currently use?
Check if you are using a product
Cleanser / Face Wash
Face Scrub / Exfoliants
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
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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