New Facial Client Intake Form

Client Intake and Consent Form

Please answer all required and read form completely. If you have any questions, please reach out to your esthetician. Thank you!
Client's Name*

First NameLast Name
Gender

FemaleMalePrefer not to sayOther
Date of Birth

MonthDayYear
Date
Phone Number*
Email Address
example@example.com
How’d you hear about us?*

GoogleSocial MediaA FriendOther
Referred by:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any of the following conditions? If yes, please select them:

CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaCirculation DisorderVaricose VeinsOther
If other, Explain.
Are you allergic to anything? (Separate with comma)*
Skin condition*

NormalOilyDryCombination
Are you pregnant or breastfeeding?*

YesNo
How do you take care of your skin at home?
What skincare products and brands do you use? Be specific.
Tell me about your skincare concerns and goals?*
Are you interested in product recommendations?*

YesNo
What is your budget for products (if any)?
How often are you wanting or able to come in for treatments?*

Every 2 weeksOnce a monthOther
If other, type your answer here.
What is your budget for treatments (if any)?
Do you use Retinol in your skincare routine?*

YesNo
When was the last time you used any retinol product?*
Are you taking any contraceptive pills or use another form of birth control (ex. IUD)?

YesNo
Are you currently on any specific kind of diet?

YesNo
Explain. Please also list common foods in your diet including protein powders, pre-workout, etc ( this helps tremendously especially with acne clients)
What medications are you currently using/taking? Oral and topical. (Please use comma to separate)
What vitamins/supplements/powders are you currently taking/using?
Have you used (in the past 6 months) or are currently on Accutane?*

YesNo
Have you received Botox, Filler, or injections in the face or lip area in the past two weeks?*

YesNo
When was the last time you received injections such as filler, Botox, Kybella, etc..?
Are you on any blood thinning medications?*

YesNo
Terms & Conditions
MUST READ:

By signing this form I acknowledge that:
- I have not been exposed to excessive sun atleast 7 days before this treatment and my skin does not feel sensitive or irritated in any way.
  I have not had any chemical peel, laser, microneedling, or any advanced skin treatment of any kind, within 14-30 days of this treatment. If yes, notify your esthetician.
- I have not had any facial waxing, within three-seven days of this treatment.
- I have informed the clinic of all health problems of which I am aware, including herpes simplex/cold sores. A facial treatment cannot be performed if a cold sore is present. You are responsible for informing the provider and rescheduling in a timely manner if necessary.
- I have informed the clinic of any use of oral or topical medications I may be using including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane.
  If you've received injectables within 14 days of your facial, you will not be able to receive any facial treatment.
- I understand that Mood Skin & Body has specific scopes of practice and that we are not able to touch, extract, cut out cysts, inflamed lesions, or abnormal spots. If you have any lesions that seem abnormal, please visit a dermatologist prior to any treatments.
- I acknowledge that my skin might experience temporary irritation, tightness, redness, dryness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.
- I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. Please ensure to list all known allergies on the Client Intake Form. Inform your physician immediately of allergic reaction if one occurs.
- I acknowledge that if I fail to use sunscreen correctly , I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure for 3 days to 2 weeks after my skin treatment. I also should especially avoid sun exposure between 10am-2pm.
- I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.
- I acknowledge that I should avoid the use of Retin-A type products or prescriptions, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for atleast 1 week following treatment.
I consent that the answers I have given are correct, true, and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments and if anything changes on this form that i will need to inform my esthetician or provider immediately.

I release Mood Skin and Body, Mood Skin and Body providers and contractors of any liability associated with any injuries, reactions, and /or current and future conditions resulting from procedures or products.
Cancellation & Appointment Policy

We kindly ask for at least 48 hours’ notice for any cancellations or changes to your appointment.
- Cancellations made within 48 hours will incur a 50% charge of the scheduled service.
- Same-day cancellations and no-shows will be charged up to 100% of the service total.
- Any changes to services on the day of your appointment (including switching or canceling services) will be considered a late cancellation and charged accordingly.
- No-shows will be charged up to 100% of the scheduled service — no exceptions.
To ensure a relaxing and professional environment for all guests, please do not bring children or additional guests to your appointment.
I have read, understand, and agree to the terms outlined in this form.

I understand that my data will be strictly confidential.

I confirm that all information in this form is true and accurate.

I confirm that if I hold some important information and complications happened, the Mood Skin and Body and providers will not be liable.

I release this spa, Mood Skin & Body and its contractors/employees and hold harmless against any claims, expenses, damages, and liabilities.
Date Signed*

MonthDayYear
Date
Client Signature

Clear
Should be Empty:

Client Intake and Consent Form

Terms & Conditions