Facial & Waxing
Client Intake & Consent Form
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Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
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Age
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Email
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example@example.com
Identifies as
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Female
Male
Non-Binary
What is your occupation?
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Contact In Case Of Emergency
Name
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First Name
Last Name
Phone Number
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Area Code
Phone Number
Relationship
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How did you hear about us?
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Walked by
Facebook/Instagram
Online Search
Referral
If referred, by whom?
May we take photographs for the purpose of documentation, potential advertising and promotional purposes?
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Yes
No
I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
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Initial
Tell Us About Your Skin
I am seeking professional skin care treatment at this time to : (Check all that apply):
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Make visible changes to my skin
Start or continue a practice of self love / self care
Feel better about the way my skin looks
Have my skin look its best for an upcoming event
Learn how to properly care for my skin
Relax and recharge
Other
My primary skin concern is: (choose one)
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Balancing (dryness, roughness, dehydration, skin feels pulled or tight)
Clarity (acne, breakouts, blackheads, whiteheads, acne scars, pimples, bumps, congestion)
Illumination (pigmentation issues, brown spots, sun damage, acne scars, uneven skin tone, broken capillaries)
Rejuvenation (fine lines, wrinkles, smile lines, crow's feet, skin laxity, sagging skin, sun damage)
Tranquillity (sensitivity, redness, rosacea, broken capillaries, allergies, easily reactive skin
My secondary skin concern is: (choose one)
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Balancing (dryness, roughness, dehydration, skin feels pulled or tight)
Clarity (acne, breakouts, blackheads, whiteheads, acne scars, pimples, bumps, congestion)
Illumination (pigmentation issues, brown spots, sun damage, acne scars, uneven skin tone, broken capillaries)
Rejuvenation (fine lines, wrinkles, smile lines, crow's feet, skin laxity, sagging skin, sun damage)
Tranquillity (sensitivity, redness, rosacea, broken capillaries, allergies, easily reactive skin
What are your other skin concerns?
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Please list ALL known allergies
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Have you ever had a facial before?
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Yes
No
I usually get facials (choose one)
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Every 2-3 weeks
Monthly
Every 2-3 months
6 Months
Infrequently
Never
What have you liked about previous facials?
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What have you NOT liked about previous facials?
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What skin care products do you use on a daily basis? (Check all that apply)
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Cleanser / Soap
Toner
Day Moisturizer
Night Moisturizer
SPF
Eye Product
Exfoliation products
Serums
Masks
Other
Please specify the type of product & brand name you are currently using from the selection you made above
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Lifestyle Choices
What is your current stress level?
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Low
Medium
High
None
How many caffeinated beverages do you usually consume?
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Please evaluate your current dietary intake.
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Very Low
Low
Moderate
High
Very High
Water
Alcohol
Sugar
Fats
Starches
Do you smoke cigarettes?
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Yes
No
How often?
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Do you use any recreational drugs?
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Yes
No
What kind?
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Describe your physical activity level:
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Sedentary
Low
Moderate
Active
Very Active
Are you undergoing any hormone replacement therapy?
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Yes
No
Females Clients
Do you experience routine PMS breakouts or acne?
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Yes
No
Are you taking any contraceptives/birth control?
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Yes
No
Please specify which product and type.
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Have you recently switched, started or stopped take contraceptives?
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Yes
No
Are you pregnant or trying to become pregnant?
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Yes
No
Are you breast-feeding?
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Yes
No
Are you currently having or due for a menstrual cycle?
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Yes
No
When was your last menstrual cycle?
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Medical Information
Please answer all questions truthfully and to the best of your knowledge
Are you currently under the care of a physician?
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Yes
No
Physician's Name
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Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician's Phone Number
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Area Code
Phone Number
Please choose any health conditions that you are have either experienced in the past or present? (Put N/A, if none)
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Acne
Anhydrosis
Arthritis
Asthma
Auto-immune Disorder
High Blood Pressure
Cancer/ Systemic disease
Claustrophobia
Cold sores
Constipation (currently)
Dermatitis
Depression/Anxiety
Diabetes
Eczema
Epliepsy/Seizures
Eyes - contact lenses
Fibromyalgia
Hay Fever
Headaches/ Migranes
Heart problem
Hemophilia
Hepatitis
Herpes
HIV/AIDS
Hypoglycemia
Hormone Imbalance
Hysterectomy
IUD (currently using)
Infectious Disease (currently)
Lupus
Meningitits
Metabolic Disorder
Metal Implants (any)
Pacemaker
Prosthesis
Psoriasis
Rosacea
Thyroid problems
None
Other
Please list all oral and topical medications/supplements you are currently taking, including vitamins.
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(Put N/A, if none)
Do you currently use:
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Accutane
Retin-A
Prescribed topical cream
No
Please specify which product or type
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What is your specific ethnic background? (for determining sensitivity factor)
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Which statement best describes your skin after 30 minutes of unprotected sun exposure?
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Always burns, never tans
Usually burns, tans with difficultly
Sometimes burns but tans easily
Very rarely burns, most often tans
Never burns, always tans
Burn/tan easily
Is there anything else that we should know about you in evaluating your skin?
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(Put N/A, if none)
Please acknowledge, agree and inital to the following:
Because certain treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I consent to the best of my knowledge that the answers I have given are correct and truthful and that I have not withheld any information that may be relevant to my treatment.
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Initial
I agree to keep the esthetician updated as to any changes in my medical profile during any session and understand that there shall be no liability on the estheticians part should I fail to do so.
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Initial
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved.
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Initial
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.
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Initial
I acknowledge that the estheticians at Emerald Reign Artistry, LLC may use products that contain tree nuts, sulfur, dairy, and gluten. These ingredients are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. (Please inform your esthetician before treatment if severely allergic, as this may make you unable to receive the service.)
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Initial
I understand that the Licensed Esthetician is not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I understand that the Licensed Esthetician reserves the right to refuse to perform treatments on anyone whom he/she deems to have a condition for which treatments are contraindicated. I further understand that the agreed service consulted is a recommendation and should not be construed as a substitute for medical examination, diagnosis, or treatment.
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Initial
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Emerald Reign Artistry, LLC and its staff from any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products and assume full responsibility thereof.
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Initial
By signing below, I acknowledge that I have read and fully understood this agreement and all information detailed above and hereby agree to comply to them.
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Name
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First Name
Last Name
Date
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After Care Instructions
Post Facial Care/Waxing Instructions
Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours.
Excessive and/or direct sunlight exposure is to be avoided immediately following the treatment especially between 10am-2pm. If some sun exposure cannot be avoided first apply a broad spectrum sunscreen. (This includes any strong UV light exposure and/or tanning beds).
It is recommended to use a sunscreen with an SPF of at least 15, preferably SPF 30 or higher and should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment.
If failed to use a minimal sunscreen, client is aware that they may be susceptible to sunburn, skin damage & hyperpigmentation.
Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer.
Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments.
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.
Enzyme peels, Dermaplane treatments, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment.
DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.
By signing below, I acknowledge that I have read and fully understood this agreement and all information detailed above and hereby agree to comply to them.
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Name
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Last Name
Date
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