New Client Intake Form

New Client Intake Form

Element Skin Therapy
Name *

First Name Last Name
Birth Date *

Month Day Year
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

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.
Date *

Month Day Year
Date
Client Siganture *

Clear
Should be Empty:

	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)