• New Client Skin Consultation Form

    The below form will collect information that will help us develop a custom treatment plan for your skin concerns and needs. The information you provide is not shared and only used for the purpose of addressing your skin concerns.

  • Client Information

  • Reason for booking a service today? Check all that apply.*

  • Would you like to receive news, promotions and special offers from Angela Branch Skin Care?*
  • 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 Background

  • Are you currently experiencing or have you ever had any of the following 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 currently taking birth control pills or have an IUD?*
  • Are you currently pregnant or breastfeeding?*
  • Are you currently undergoing any hormone therapies or taking any infertility drugs?*
  • 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 allergies, including foods, skin products or ingredients, animals, etc.?*
  • Do you smoke?*
  • Are you having at least one bowel movement per day?*
  • Have you had any excessive sun exposure in the last week?*
  • Will you be having excessive sun exposure on a vacation in the near future?*
  • Are you in the habit of using tanning booths?*
  • Do you wear contact lenses?*

  • If yes, we ask that you please remove them before any facial service.

  • Do you wear contact lenses?
  • Do you have any sinus problems?*
  • Do you have any sinus problems?
  • Have you ever experienced claustrophobia?*
  • Have you ever experienced claustrophobia?

  • Skin Care

  • How would you describe your skin?*
  • What current skin conditions are you currently concerned with or experiencing? Check all that apply.*

  • How long have you been dealing with these specific concerns/challenges?*

  • Have you ever/are you currently using Accutane® (acne medication)?*
  • Are you using or have you used Tretinoin, Retin-A, Renova, Adapalene or any other topical/oral prescriptions skin products from a physician?*
  • Are you using or have you used Tretinoin, Retin-A, Renova, Adapalene or any other topical/oral prescriptions skin products from a physician?*
  • Are you using any other topical prescriptions from a physician not listed above?*

  • What is your current AM skincare routine?

    Please provide the brand name, full product name and frequency of use.

  • What is your current PM skincare routine?

    Please provide the brand name, full product name and frequency of use.
  • What skin care products are you currently using? Check all that apply.
  • Have you ever received any of the following treatments?*
  • 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 received any facial treatment or procedure not listed above?*
  • Have you experienced sensitivity from any skincare products?*
  • Are you currently or have you ever experienced bouts of skin blotching, burning or itching?*
  • Have you been waxed or shaved within the last 72 hours?*
  • Are you currently using any non-prescription (over-the-counter) products that contain the following ingredients?*
  • Have you ever received a professional facial or skin care treatment?*

  • Please Note: Some facial services use CBD products which are derived from the Hemp (Cannabis Sativa) plant.

    Cannabidiol (CBD) is a compound found in the Hemp (cannabis) plant called a phytocannabinoid. It is biologically impossible to become intoxicated from using CBD topically or internally as this compound is non-psychoactive. Pure CBD is used in the skincare products. The benefits to the skin include anti-inflammatory, antioxidant, anti-bacterial, moisturizing, balancing. "Full Spectrum" Hemp oil does contain over 100 phytocannabinoids in the cannabis plant, including up to 0.3% THC, which is another compound found in the Hemp (cannabis) plant. THC is non-intoxicating when applied to the body topically. Furthermore, when applied topically, both CBD and THC do not enter the blood stream and should not ever appear on a drug panel. There may be Full Spectrum internal tinctures offered and retailed. If you are subject to drug panels, you should not ingest Full Spectrum Hemp oil. If you have more questions about this, please do not hesitate to ask.
  • I understand what CBD is and consent to the topical use.
  • I understand what Full Spectrum Hemp Oil is and consent to the topical use.

  • 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 Angela Branch Skin Care can not guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that, because skin care services and massage therapy involves 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 and massage therapy from the practitioners.

  • Photo and Video Release

    I understand that my photos will be taken to obtain a baseline record of my skin and to monitor treatment effects, but will only be shared/released with my consent per the below:
  • I give my permission for Angela Branch Skin Care to release for marketing purposes any videos or photos of services performed on me and any information regarding these services that I have received including but not limited to its website, Instagram, Facebook, TikTok, print, visual and marketing materials under the following circumstances:.*

  • CANCELLATIONS OR RESCHEDULING POLICY

    To secure your appointment at Angela Branch Skin Care, we require a credit card to be placed on file and a 50% booking fee at the time of your appointment request. The booking fee will be applied towards the total cost of your scheduled service. The remaining balance will be due at the completion of your appointment. Should you need to cancel or reschedule your appointment a 24-hour notice is required prior to the scheduled appointment start time. 

    CANCELLATION OR RESCHEDULING FEES

    By booking an appointment with Angela Branch Skin Care, you authorize any applicable fees to be charged to the credit card on file in accordance with our cancellation policy. This includes a charge of 50% of the scheduled service(s) cost for cancellations made less than 24 hours before the appointment start time and a charge of 80% of the scheduled service(s) cost for no-shows. You acknowledge and agree to these terms, and understand that booking fee may be applied toward these cancellation fees.

  • LATE ARRIVAL POLICY

    Please be mindful that the appointment time you selected is reserved specifically for you. If you arrive more than ten minutes late, we will adjust the treatment to the remaining time as best we can but your appointment may need to be rescheduled if you are more than 15 minutes late. Treatments scheduled for 30 minute or less, will have to be rescheduled if you are more than 5 minutes late.

    We will be unable to accommodate late arrivals for any services if there are no openings in my schedule. Regardless of the circumstances, you are still responsible for the full cost of your originally scheduled appointment. Thank you for understanding.

  • 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 recieving are for the basic purpose of skin care 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 skin care services involves 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 skin care services from the practitioners.

    In taking part in this service, I agree, to the fullest extent permitted by law, to forever release, indeminify, defend and hold harmless Angela Branch Skin Care LLC and its affiliates, related companies, owners, 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 indemifiy, defend and hold harmless the Released Parties from any and all third party claims arising from any acts, errors or omissions. 

  • By signing below I certify that:

    • I have not had close contact with or cared for someone diagnosed with COVID-19 within the last 7 days.
    • I have not experienced any cold or flu-like symptoms within the last 7 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 7 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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    2 digit month, 2 digit day, 4 digit year
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