New Client Intake Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Birthday

Date

How do you hear about me?

Name of Referral

The following questions will insure you have the best skin care service possible with the best results. Please answer all questions. Speak to your skin care specialist if you are unclear or have any questions prior to the service.

Have you use a Retin-A, a Retinol OTC, Renova, any form of Alpha Hydroxy Acid (AHA), prosfessional or at home micro-dermabrasion, glycolic peel, or any other peels in the last 72 hours.

Are you currently taking medications? If so please list all including over the counter?

Any current skin care issues?

Any known allergies?

Any of the following conditions?

Have you been diagnosed with Covid-19 within the last 2 weeks?

Experienced ANY flu symptoms in the last 2 weeks?

Allow before & after photos to be taken?

I am aware and understand the no call/no show and canceling less than 24 hours will result in a cancellation fee. (100% of service). Late arrivals must notify me prior to their appointment. (5 minute grace period) Arriving more than 5 minutes late you will be required to pay a $10 late fee and will be asked to reschedule.

I have completed the Client Form accurately, with a sound mind and free of any mind altering drugs, legal or otherwise, to the best of my knowledge and release liability of Jasmin Harrison and it's Owner/agents of any damages or harm caused if I failed to mention any conditions that would otherwise be considered a contraindication to any services provided by Jasmin Harrison or it's owner/agents.

Today’s date

Date

Signature (If under 18 parent/guardian signature)