• Aesthetic FX Online Intake Form

    Please take a moment to carefully read and complete this form. Sign where indicated.
  • Birthday
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  • Format: (000) 000-0000.
  • Reason for booking a service today? Check all that apply.

  • How would you like to receive news and special offers from Aesthetic FX?
  • How did you hear about us?

  • This intake form is used to evaluate your individual service needs. We will maintain the confidentiality of this information, and will disclose this information only: (i) to our staff members, (ii) to quality assurance and quality control personnel, (iii) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.

  • Let’s get personal!

    Please answer these questions to help us provide the best service for you.

  • Your Health

  • Are you experiencing any of the following health conditions? Check all that apply.

  • Do you have any other health condition(s) not mentioned here?
  • Within the last year, have you had any health problems that have affected or could affect your skin?
  • Are you using any topical prescriptions from a physician?
  • Do you wear contact lenses?

  • I ask that you please remove before any facial service.

  • Do you have metal implants, a pacemaker or body piercings?
  • Do you have any allergies, including foods, skin products or ingredients, animals, etc.?
  • Do you have any sinus problems?
  • Have you ever experienced claustrophobia?

  • Skin Care

  • What current skin conditions are you currently concerned with? Check all that apply.

  • What skin care products are you currently using? Check all that apply.

  • Have you had any chemical peels, microdermabrasion or any resurfacing treatments within the last month?
  • Have you had any dermaplaning, microneedling, Botox, injectables, dermal fillers or any other advanced facial or cosmetic treatments within the last month?
  • Have you experienced sensitivity from any skincare products?
  • Are you currently or have you ever experienced skin blotching, burning or itching?
  • Have you been waxed or shaved your face within the last 72 hours?
  • Have you used Retin-A, Renova, Adapalene or any other prescription skin products within the last three months?
  • Have you ever/are you currently using Accutane® (acne medication)?
  • Are you currently using any products that contain the following ingredients?
  • Please specify if any of the following apply to you:
  • Have you ever received a professional facial?

  • COVID-19 Consent and Liability Waiver

    I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Aesthetic FX can not guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that, because skin care services involve 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 and give consent to receive skin care services from the practitioner.

  • Photo and Video Release

    Before and after pictures may be taken to track your skin's progress.
  • I give my permission for Aesthetic FX to post any videos or photos of services performed on me and any information regarding the services that I have received to its social media sites including its website, Instagram and Facebook.

  • CANCELLATIONS OR RESCHEDULING POLICY

    Should you need to cancel or reschedule your appointment, please note the following policy: 

    • A 24-hour notice is required for any service appointment.

    CANCELLATION OR RESCHEDULING FEES

    All appointments not cancelled or rescheduled within the time frame specified above will be assesed a $25 fee. All same day cancellations will be assessed a fee equal to 50% of the service cost. No refunds. All services paid in full will not be refunded for any reason. 

     

    I confirm (to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my service. I understand that the services I am receiving are for the basic purpose of skin health and wellness as a result of my participation in this session I could suffer an injury and hereby agree that I am doing so at my own risk. I understand that, because skincare services involve 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 and give consent to receive massage and skincare services from the practitioners.

    In taking part in this service, I agree, to the fullest extent permitted by law, to forever release, indemnify, defend and hold harmless Aesthetic FX and its affiliates, related companies, owners, the family of owner, friends, workers, contractors, officers, directors, members, employees, agents, representatives, partners, and licensors (collectively, the “Released Parties”) from any and all claims, liability, damages and/or costs (including attorneys’ fees) which, I might have or be entitled to assert as a result of or related to any physical injury or otherwise, including without limitation of death, property damage or loss sustained in connection with the services being rendered on my premises. I also agree to indemnify, defend and hold harmless the Released Parties from any and all third party claims arising from any acts, errors, or omissions.

    • I have not had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days.
    • I have not experienced any cold or flu-like symptoms within the last 14 days, including but not limited to shortness of breath or difficulty breathing, cough, fever, sore throat or any respiratory illness.
    • I have not traveled outside of the United States or outside of my state of residence in the past 14 days.
    • I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
    • I have read and fully understand the above paragraphs and I understand the services being rendered and accept the risks.
  • Today's Date
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