GhostKosmos Client Intake & Liability Form / Non-Disclosure agreement
Only fill this form out after you have booked an appointment. Please read my policy thoroughly!
Client Name
First Name
Last Name
Gender / Pronoun
*
Male, He-Him
Female, She-Her
X They/Them
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Where did you hear about us?
*
Have you ever had a facial treatment? If yes, where?
Have you been exposed to, tested positive, or received the Covid 19 vaccine? Select all that apply
*
Yes
No
Vaccinated (second dose)
Do you have any of the following conditions? If yes, please select them:
Cancer
Hypertension
Hypotension
Metal Implants
Pacemaker or Defibrillator
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hormonal Imbalance
Epilepsy or Seizures
HIV AIDS
Hepatitis A/B/C
Migraines/Headaches
Psoriasis
Rosacea
Eczema
Bruise Easily
Immune Disorder
Lupus
Keloid Scarring
Blood Clot Disorder
Skin Disease
Circulation Disorder
Blood thinners
N/A
Other
Skin type? (Select all that apply)
*
Dry
Oily
Acne prone
Reactive / Sensitive
Combination
Normal / Clear
What are your main skin concerns that you would like to address?
Allergies or sensitivities including food?
*
Are you pregnant?
*
Yes
No
Are you taking any contraceptive pills?
Yes
No
Are you breastfeeding?
Yes
No
Do you consent to photos and videos during your service?
*
Yes
No
Please list your FULL AM/PM skincare regimen, as well as any medications prescribed by a doctor or dermatologist for skin conditions. (Do not include make up or cosmetics.)
Terms & Conditions
I understand that my data will be strictly confidential. GhostKosmos Aesthetics does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information, refuse and or do not follow proper aftercare and complications occur, GhostKosmos Aesthetics and its entities will not be held liable. I release GhostKosmos Aesthetics and hold harmless against any claims, expenses, damages, injuries and liabilities. By submitting this form, Client agrees not to attack/criticize GhostKosmos Aesthetics, it’s entities, and any of its employees, associates or partners publicly (on public forums, blogs, social networks, word of mouth, reviews etc) at any time during or subsequent to contract period or after a service in the clinic. Similarly, client agrees not to seek for seo advice on seo forums, blogs, community groups or any social media in a way that brings bad name to the company or any of its employee, associate or partner. In case of breach of this clause, client agrees to pay legal fees and damages to GhostKosmos Aesthetics and it’s entities. I understand that signing this form also indicates an understanding of late fees, cancellation fees, and policies.
Client Signature (sign with finger)
Date Signed
-
Month
-
Day
Year
Date
Print Form
Submit
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