Client Skincare Intake and Consent Form

Name*

First NameLast Name

Date of Birth*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Occupation*

Facebook/InstagramOnline SearchReferralOther

If referred, by who?

YesNo

If yes, what have you been treated for? :

YesNo

If yes, please explain:

If other, please explain:

Please list any other allergies or sensitivities:

List any medications, supplements, or herbal remedies you currently take (enter n/a if none):*

YesNo

HighMediumLow

YesNo

If yes, when was your last facial or skin treatment?

Date

YES, within the last 7-10 daysYES, within the last monthYES, within the last 2-3 months

YesNo

If yes, which products or brands?

YesNo

If yes, date of last treatment?

Date

Normal (no visible blemishes, fine pores, smooth textureOily (enlarged pores, excess oil)Acne (cystic or nodules)Dry (dull, visible lines/wrinkles, feel tight)Aging (dry, very visible deep lines/wrinkles)Combination (oily and dry patches, oily t-zone, hormonal acne)Sensitive (reactive to fragrance, often irriated)Not sure

YesNo

What is your daily skin care regimen? *

Please upload a picture of your current regimen.*

Browse Files

AlwaysOftenSometimesNever

What are your specific concerns at this time regarding your skin?*

What is your skin care goal?*

By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following: I give my permission to receive facials & skin care treatments. I I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my esthetician.understand that results are not guaranteed and for maximum results, more than one service may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels, or acne conditions. I have been informed of the possible negative reactions and the expected sequence of the healing process. (drying, irritation, redness, and peeling of the skin.) I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.I understand that the esthetician does not diagnose illnesses or injuries, or prescribe medications. I have clearance from my physician to receive facials & skin treatments. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure. I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment. I understand the importance of informing my esthetician of all medical conditions and medications I am taking, and to let the esthetician know about any changes to these. I understand that there may be additional risks based on my physical condition. I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so he/she may adjustaccordingly. I understand that I or the esthetician may terminate the session at anytime. If I have questions or concerns, I will address these with my esthetician before seeking outside sources. I have been given a chance to ask questions about the session and my questions have been answered. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I understand that this agreement will remain in effect for this procedure and all future procedures conducted by my Esthetician. I, therefore, release Esthetics by Zay and its staff of from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature*

Client Intake & Consent Form

Medical History

Your Skin