Client Intake/Consent Form

Name

First Name Last Name

Date *

Date

Birth Date *

Phone Number *

Area Code Phone Number

Emergency Contact *

First Name Last Name

Todays Service?

How did you learn of us? we would like to say thankyou!

Skin Type

Normal Combination Dry Oily Rosacea Acne

Emergency Contact Phone Number *

Area Code Phone Number

Are you pregnant, breastfeeding, or nursing? *

Yes No

Are you currently taking any prescribed medications (such as antibiotics, blood thinners, acne medications/anything from a dermatologist, etc)? If yes, please list them below: *

Do you have any known allergies/skin sensitivities? Please list if any. *

Are you currently using Retinol, Retin-A/Tretinoin, Adapalene, or any Vitamin A derivatives? *

No Yes

If so, how recent/ how often?

Have you recently received Botox/ Dermal Fillers? *

No Yes

Have you recently received a chemical peel or laser treatment? *

No Yes- in the last month Yes-in the last 2-3 months

Did you undergo any major surgery in the past 90 days? If yes, please describe:

I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I give consent for all future treatments. I acknowledge that the esthetician holds the right to terminate the session at any time. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. I understand that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I release the esthetician from any and all liability associated with any injuries/current and future conditions resulting from the skincare procedures or products used and assume full responsibility thereof.

Signature *

First Name Last Name

Client Intake/Consent Form

Medical / History Data

Authorization