New Client Intake Form

New Client Intake Form

Element Skin Therapy
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
For appointment reminders, follow-ups, etc.
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*

Website / Online SearchSocial MediaReferralOther
If referral, please list name

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. I understand prices are subject to change and I should refer to Element Skin Therapy's Vagaro booking site for the most updated prices. 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 hereby release, waive, and discharge Element Skin Therapy, its owners, employees, contractors, and affiliates from any and all liability, claims, demands, or causes of action arising out of or related to any loss, damage, injury, or adverse reaction that may be sustained as a result of the services received. I affirm that all medical and skincare history I have provided is accurate and complete to the best of my knowledge.
Date*

MonthDayYear
Date
Client Siganture*

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