New Client Informed Consent

Please fill out this form so that we can best serve you! If you are an Initial Acne Consult client, please fill out this form instead.

Date of Appointment*

Please select which service(s) you will be receiving:*

Name*

First NameLast Name

Date of Birth

Phone Number*

Please your preferred phone number.

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list any allergies you have:

Have you ever used hair color before?*

YesNo

Have you ever had an allergic reaction to hair color?*

YesNo

Have you ever had your brows or lashes tinted?*

YesNo

Have you ever had your lashes lifted, or permed?*

YesNo

What did you think of your previous experience? If you had an adverse reaction to a previous tinting or lifting, please explain:

Do you wear contacts?*

YesNo

Although every precaution will be made to ensure your safety and well-being before, during and after your tinting and/or lifting application, please be aware of the possible risks below. Please indicate that you understand:*

I understand that tinting and/or lifting lashes or brows has some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging or burning, blurry vision and potentially blindness should the product enter into the eye.I understand that if the lifting agent, tinting agent, developer, or mixture of both accidentally comes into contact with my eye, my eye will be flushed with water and medical attention may be required.I understand that some irritation, itching or burning may occur to the skin which comes in contact with the product.I understand that there may be some residual dark staining left on the skin following the tinting process of either my lashes, brows or both. This will fade and go away within a short time.I understand that, while every attempt will be made to provide me with my chosen color, everyone’s hair absorbs color differently and my final results may not be the color I initially wantedI understand that over the course of several weeks, the tint will gradually lighten and fade. Re-tinting will be required to keep the new color fresh. Most clients need to re-tint every 3-4 weeks. The lift will gradually drop, and re-lifting will be required every 6-12 weeks to maintain results.

Lash lift aftercare. Following the correct home aftercare after your lash lifting service is essential to attaining optimal results. Please indicate that you understand:*

I understand that I must avoid moisture for 24 hours - don't get your eyelashes wet, and avoid steam. The lash lift can drop if lashes are exposed to too much moisture within the first 24 hours.I understand that I must avoid touching your eyelashes - oils from your hands and friction from touching, rubbing, or playing with your eyelashes can cause the lift to droop and can cause eyelashes to fall out earlyI understand that I must avoid eye makeup remover for the first 48 hours - makeup removers can cause the lash lift to dropI understand that I must not use shampoos, conditioners, makeups, creams, eye serums or oils on the lashes or around the eye are for first 24 hours - these can change the color of the tint and can cause the lash lift to dropI understand that I must avoid sleeping on my face for 24 hours - avoid sleeping face down, mashing the side of your face into a pillow, and eye pillows and eye masks the night after your lash lift appointment. This can cause the lash lift to drop.

Waxing is the removal of hair using either hard or soft wax. The wax is typically applied in the direction of hair growth, and removed against the direction of hair growth. This results in the hair being removed from the follicle by the root. The wax can stick to the skin as well as the hair, and can cause redness, pain, and inflammation. If not done properly or unknown skin conditions are not disclosed, waxing could lead to painful or infected ingrown hairs, or bruising. When the client keeps the trained professional informed about their skin, the results are smooth skin that can last up to 6 weeks.

Sugaring hair removal, an ancient middle-eastern practice, is similar to waxing, but the paste sticks to the hair not to the skin, which causes less redness, pain, and inflammation. The paste is typically applied against the direction of hair growth, and removed with the direction of hair growth. This results in the hair being removed from the follicle by the root. Since the mixture is made of natural ingredients, there can be less irritation than waxing and it washes off easily with water. Just like waxing, if not done properly or unknown skin conditions are not disclosed, sugaring could lead to painful or infected ingrown hairs, or bruising. When the client keeps the trained professional informed about their skin, the results are smooth skin that can last up to 6 weeks.

What skin care products are you currently using? (Please include both over-the-counter and prescription products) If you do not use any products in a category, please write "None"*

	Product name(s)
Cleanser(s)
Toner(s)
Moisturizer(s)
Sunscreen(s)
Serum(s)
Vitamin A (Retin-A, Differin, etc.)
Scrub(s)
Mask(s)
Other

Have you used any hydroxy acid (eg. glycolic, mandelic, lactic, and/or salicylic products in the past 48-72 hours? (Ingredients are typically found in anti-acne and anti-aging products)*

YesNo

Are you currently using or have you used within the past year: Retin-a, Renova, Differing, or isotretinoin (Accutane) an oral form of Retin-a? (Typically found in anti-acne and anti-aging products)*

YesNo

Are you using any other skin thinning products and/or drugs?*

YesNo

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

YesNo

Do you use a tanning bed?*

YesNo

Do you have diabetes, lupus, or any auto-immune disease?*

YesNo

If yes, please describe

Have you ever been treated for cancer?*

YesNo

If yes, please describe

Please list any illnesses or conditions you are being treated by a physician for:

Please list any medications you are taking, including over-the-counter herbs, vitamins, and supplements:

I understand that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.*

I understand

Please be aware of the following information and possible risks:*

I understand there are certain contraindications that would preclude me from receiving waxing or sugaring hair removal, such as uncontrolled diabetes, melanoma, open wounds, varicose veins, and sunburn.I understand that the use of (AHA) alpha hydroxy or glycolic acids, Retin-a, Renova, or Accutane within 72 hours of waxing or sugaring hair removal is contraindicated and may cause the skin to lift or peel.I understand that the use of tanning beds and/or sun exposure immediately after waxing or sugaring hair removal is contraindicated.I understand that waxing or sugaring hair removal may result in bruising, ingrown hairs, and skin irritation, redness or inflammation.I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.I understand that waxing or sugaring hair removal may permanently damage hair follicles, resulting in permanent hair loss.

Post-Treatment Home Care - Waxing and/or Sugaring:

To ensure maximum comfort and benefit after the treatment, it is important to follow the steps below at home. I acknowledge that I am advised to:*

Avoid applying heat to the waxed area for 12 to 24 hours. This includes hot baths, sauna, and steam.Use an anti-acne lotion for face, back and chest following the treatment and twice a day until breakouts are gone. Use only an anti-acne product recommended by your skin care professional.Avoid suntanning for 12 to 24 hours. This includes any strong ultraviolet (UV) light exposure or tanning bed treatments.Avoid applying highly fragranced products to the waxed area. This includes, perfume, scented body lotions, antiperspirants, cosmetics, or feminine hygiene sprays. Only use professional products, recommended to you by the skin care therapist who performed the waxing service.Avoid using harsh abrasive or exfoliates in the waxed area. However if you are prone to in-grown hairs, the day after your waxing treatment, exfoliate newly waxed area with a loofah to avoid future problems.Avoid applying high SPF sunblocks to the waxed area for 12-24 hours after the waxing service. Sunscreen chemicals can be irritating to the newly waxed skin. This includes self-tanning products and tan accelerators.Any pinking of the skin should disappear within 6 to 8 hours after the waxing treatment. Slight pinking is normal, and indicates that the hair was removed from the root, rather than superficially broken off, as in shaving. This is the reason that professional waxing or sugaring lasts so much longer.For best results, repeat your professional waxing or sugaring every 4 to 6 weeks depending on the area and your individual hair growth rate.

Do you have a history of keloid scarring, diabetes, autoimmune disease, active herpes blisters, or any other existing condition that may interfere with the outcome of this treatment?*

YesNo

Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma? (Please select all that apply)

Yes, hyperpigmentation (darkening)Yes, hypopigmentationNo, neither

Have you had any facial surgical procedures, piercings, tattoos, permanent cosmetic procedures, or other chemical peels within the past year?*

YesNo

If yes, please elaborate:

Have you had any recent radioactive or chemotherapy treatments, sunburns, windburns, or broken skin?*

YesNo

Have you recently waxed or used a depilatory (ie: Nair) on the area to be treated?*

YesNo

How would you describe your skin? *

NormalCombinationOilyDry

Are you currently pregnant or breastfeeding?*

YesNo

Dermaplaning is a form of manual exfoliation similar in theory to microdermabrasion but without the use of suction or abrasive crystals. An esthetician grade, sterile blade is stroked along the skin at an angle to gently “shave off” dead skin cells from the epidermis. Dermaplaning also temporarily removes the fine vellus hair of the face, leaving a very smooth surface

A chemical peel treatment is a form of chemical exfoliation which uses hydroxy acids to gently and effectively exfoliate dead skin cells and/or oils from the epidermis.

SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):

I. Very fair skin; blonde or red hair; light-colored eyes; freckles commonII. Fair skinned; light hair, light eyesIII. Very common skin type; fair; eye and hair color varyIV. Mediterranean Caucasian skin; medium to heavy pigmentationV. Mideastern skin; rarely sun sensitiveVI. Black skin; rarely sun sensitive

Have you had chemical peel treatments in the past?*

YesNo

Have you had dermaplane treatments in the past?*

YesNo

If yes, when?

Describe your experience with previous treatment(s):

Although every precaution will be taken to ensure your safety and well-being before, during, and after your chemical peel treatment, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please indicate:*

Although it is impossible to list every potential risk and complication, I understand that recognized contraindications include: Active acne, Active infection of any type, such as herpes simplex or flat warts, Any raised lesions, Any recent chemical peel procedure, Chemotherapy or radiation, Eczema or dermatitis, Family history of hypertrophic scarring or keloid formation, Hemophilia, Hormonal therapy that produces thick pigmentation, Moles, Oral blood thinner medications, Pregnancy, Recent use of topical agents such as salicylic acids, glycolic acids, alpha-hydroxy acids and Retin-A, Rosacea, Scleroderma, Skin Cancer, Sunburn, Tattoos, Telangiectasia/erythema may be worsened or brought out by exfoliation, Thick, dark facial hair, Uncontrolled diabetes, Use of Accutane within the last year, Vascular lesionsI understand that there are risks and complications associated with having a chemical peel and that, very rarely, permanent damage occurs. I understand that my skin therapist will take every precaution to minimize or eliminate negative reactions. I acknowledge that I have been informed of the possible negative reactions (ie: intense erythema, blisters, sores, welts, scabs, or other reactions), and the expected sequence of the healing process (ie: dryness, irritation, redness, and/or peeling of the skin).I understand that this chemical procedure is expected to make the skin feel uncomfortable while being applied but agree to inform the skin therapist immediately if I have questions, concerns, or am overly uncomfortable during treatment or after I return home. In the event that I may have additional questions or concerns regarding my treatment or the suggested home product/post-treatment care, I will consult my skin therapist immediately. I understand that if I choose to consult a physician, that I do so at my own expense.I understand that I should not have a chemical treatment if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.I understand and agree to follow the home-care instructions and recommendations provided by my skin therapist. I understand that I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen, avoiding the sun/tanning booths, avoiding extreme weather conditions, avoiding excessive exercise, and using a moisturizer specifically recommended to me by my skin therapist. I realize and accept that the consequences of failure to adhere to these instructions may yield undesirable results.I understand that results are not guaranteed and for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels, or acne conditions.I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my skin therapist.I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my skin therapist.

To ensure maximum comfort and benefit after the treatment, it is important to follow the steps below at home:. I acknowledge that I am advised to:*

Avoid applying heat to the waxed area for 12 to 24 hours. This includes hot baths, sauna, and steam.Avoid suntanning and direct sunlight exposure for 12 to 24 hours. This includes any strong ultraviolet (UV) light exposure or tanning bed treatments.If some sun exposure cannot be avoided, first apply sunscreen with an SPF of 30 or greater. Sunscreen (with at least a SPF of 15) should become a part of your daily skin care regimen as your skin will become more sensitive to the sun as a result of this treatmentAvoid applying highly fragranced products to the treated area. This includes, perfume, scented body lotions, antiperspirants, cosmetics, or feminine hygiene sprays. Only use professional products, recommended to you by the skin care therapist who performed the waxing service.Avoid using harsh abrasive or or chemical exfoliants in the treated area. (eg. glycolic, salyclic, Differin, vitamin A)Avoid peeling, rubbing, scratching the kin at any time, whatsoever. This WILL cause damage and compromise results as well as possibly cause severe scarring.If you experience painful areas of the treated area, contact your skin care therapist immediately, especially if you are prone to cold sores. Any blisters that form will need to be reported immediatelyCleanse the treated area with water and a gentle cleanser, and gently moisturize the treated area with a gentle, calming moisturizer for the first 48 hours unless otherwise indicated by your skin care professional

How did you hear about us?*

If Referral, please list name (we have a referral program!)

I consent to “before-and-after” photographs for the purpose of documentation, potential advertising, and promotional purposes.*

YesNoNot applicable - bikini or Brazilian hair removal

Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. Please do not forget to confirm your appointment when you receive your reminder. In the event of cancellations received less than 24 hours prior to appointment a cancellation fee of 50% of the reserved service booking will incur. (Except in cases of contagious illness as described below.) No Shows will be charged 100%*

I understand the reservation and cancellation policies at Kyanne Marie Skin Care and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments.I understand that hair removal services can be more painful while menstruating, but that they can still be safely performed. If I cancel within 24 hours due to menstruation I will still be charged accordingly.I understand that hair must be at least 1/4” long (about the length of a grain of rice) for successful hair removal. If I arrive to my appointment and my hair is too short, I will still be charged for the appointment.I understand that if I have multiple services scheduled, any changes to those services (eg. removing or swapping services) needs to be settled prior to 24 hours. If removing services same day, I understand that is time that could have served another client, therefore I will be charged accordingly

If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. There is no penalty or time-frame required in this case, for your safety and that of other clients.*

I understand

Have you had a fever in the last 24 hours of 100°F or above?*

YesNo

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*

YesNo

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*

YesNo

I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.*

I understand

I have read the above information. If I have any concerns, I will address these with my skin care therapist. I give permission to my therapist to perform the procedure(s) we have discussed, and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed on the date of service.

I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.

The Sugar Coated Sugar and Skin™ is located at:

358 Holladay Ct.
Loveland, CO 80537

Please park in front of the third stall in the driveway or in the center parking.

Text or DM me when you get there, and I'll let you know when you can come inside!

Please park in front of the third stall in the driveway or in the center parking.*

Got it, I’ll wait in my car and text Kyanne at (970) 460-8801 when I arrive

Client Name*

First NameLast Name

Guardian Name if Client Under 18

First NameLast Name

Client Signature (Guardian Signature if Client under 18)*

Today's Date*

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Informed Consent - New Client

About You

Lash & Brow Enhancements

Waxing and/or Sugaring Hair Removal

Facial Treatment

Dermaplane or Chemical Peel Treatment

COVID-19 Information