Skincare Intake & Consent Form

Skincare Intake & Consent Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number or Preferred Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Friend/FamilySocial mediaGrouponGoogleOther
Your Medical History
Are you currently under the care of a physician?*
Hormone ImbalanceHigh Blood PressureHeart ConditionAuto-Immune DisorderEpilepsy/SeizuresHIV/AIDSDepression/AnxietyCancerDiabetesArthritisAsthmaCold soresLupusHeadaches/MigrainesThyroid DisorderOtherMetal ImplantsNone
AsprinFruitsLidocaneShellfish or SeaweedTree nutsFragrance/Essential OilsSunscreenDairy/LactosePollenNoneOther
List medications / supplements you are currently taking:
What is your diet like? (How many caffeinated beverages do you drink a day, do you eat fast food, processed food, mostly lean protein, lots of veggies, love dairy, eat lots of peanut butter, etc.) These answers are very important for acne clients.
Have you received Botox or fillers? If so, when?
What are your skin goals?*
Normal (no visible blemishes, small pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combo (oily and dry, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic, nodules, impactions)Dry (dull, visible lines, wrinkles)
Wrinkles/Fine linesHyperpigmentation/Sun DamageAcne/Acne ScarringRedness/RosaceaAgingMelasmaSensitivityOther
Bar soapCleanserTonerSerumEye CreamMoisturizerMaskSPFVitamin A (Retinol)Exfoliant (physical or chemical)
What product brand(s) do you use?*
Do you experience routine breakouts or acne?
Have you been diagnosed with Dermatitis, Eczema, Psoriasis or Rosacea?
Waxing/SugaringThreadingLaser/Electrolysis
AccutaneRetin - APrescribed topical creamDifferinOther
AHA (glycolic or lactic acid)BHA (salicylic acid)Vitamin A derivative (retinol, retinoids)Exfoliating scrubsMandelic AcidNot sure
Yes, within the last monthYes, within the last 2-3 monthsNo
Female Clients
Are you taking birth control?
Are you pregnant or breast feeding?
I understand that cancellations must be done with, at least, 24 hours notice. Failure to do so, will result in a charge of 50% of my scheduled service.I understand that if I do NOT show up to my scheduled appointment, I will be charged 50% of the cost of my scheduled service.I understand that if I am more than 15 minutes late to my appointment, my appointment may be subject to a shortened time or rescheduled. I am responsible for the full treatment cost.
I confirm, to the best of my knowledge, that the answers I have provided are correct and I have not withheld any information that may be relevant to my treatment. The treatments I receive with Good Vibes Aesthetics are voluntary and I release Good Vibes Aesthetics and/or the skin care professional from any and all liability.

I understand that it is my responsibility to review and discuss any questions or concerns I may have with my Aesthetician.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Skincare Intake & Consent Form

Your Medical History

Female Clients