Name Nombre Apellido D.O.B. blank Age AddressDirección de la calle Address Line 2 Ciudad Estado Zip How you prefer to be contacted Text Call Email Phone Número de teléfono Email Email May we add you to our email list? Yes No Whom may we thank for your referral? Emergency Contact Phone Número de teléfono
Do you have any allergies? Yes No If yes, blanks
Have you been or are you currently under the care of the physician, dermatologist, or other medical professional Yes or No Yes No Explain blanks
Have you ever used products that caused a bad skin reaction? Seleccione Yes No Describe blanks
Do you have any metal implant in your body? Yes No Where
Are you pregnant or breastfeeding? Yes No
Do you develop cold sores/fever blisters? Seleccione Yes No Last outbreak? blanks
Are you taking any medication at this time? (Including birth control, hormone replacement, herbal supplements, antibiotics) blanksblank
Do you do regular dermal filler injections? Botox? Collagen? Restylane? Yes or No Yes No When blanks
Are you currently taking Accutane? Yes or No Yes No Type Option 3 If yes, How long? blanks
Do you currently have windburn, sunburned, red face? Yes No If Yes, Why blanks
Do you wear contact lenses? Yes or No Yes No (Remove them for facials)
I have completed this form to the best of my ability and knowledge and agree to inform my esthetician of any changesto the information listed on all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my esthetician and Golden Swan Studio for any injury or damages incurred due to my misrepresentation of my health history.
I, blanks (name), do hereby agree to the following. I am allowing Golden Swan Studio to take photos of my treatment and/or treated areas to be used to the purpose of monitoring my progress.In addition: I give permission for my photos to be used for advertising blank (Initials). I give permission for my photos to be used on the Golden Swan Studio website.blank (Initials). My identity will remain anonymous. blank (Initials). I give permission for my photos to be used for education. blank (Initials).
By signing here, I attest that I have read and understand all the policies presented by Golden Swan Studio: