New Client Consultation Form

Chemical Peel Consultation Form & Waiver

Must be completed before appointment to allow your esthetician time to review. Please answer completely and honestly, this is for your safety!
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about us?*

Google SearchYelpFacebookReferralOther
If Referral, please list name
If Other, please let me know
Your Skin
What do you hope to achieve with your facial?*
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail:
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, what type and when?
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Is there a brand(s) you prefer or have had good results with?
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services on your face or neck in the last 30 days?*

WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last treatment date:
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

Yes, within the last monthYes, within the last 2-3 monthsNo
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOther
If other, please list
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Are you a smoker? *

YesNoSocial
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level*

LowMediumHigh
FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues? *

YesNoN/A
If yes, please specify
Are you undergoing any hormone replacement therapy?

YesNo
If yes, please specify
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving? *

YesNoN/A
I understand, have read and completed this questionnaire truthfully. 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 this skin care professional from liability and assume full responsibility thereof.*

Yes
Pre-Care Instructions
One week before your peel:
- Discontinue any topical prescriptions or any products containing Retinol or Vitamin A
- Stop all waxing, electrolysis, depilatory creams, and laser hair removal treatments
- Avoid direct sun exposure (indoor and outdoor)
- Do not receive Botox or dermal fillers
- Do not have another treatment unless recommended by your esthetician
The day of your peel:
- Discontinue all use of alpha hydroxy acid (AHA), beta hydroxy acid (BHA) and benzoyl peroxide
- Stop any exfoliating products that may be drying or irritating
- Do not shave or pluck your face the day of your peel
I have read and completely understand the pre-care instructions:*

Yes
Post-Care Instructions
Immediately Post-Peel:

DO NOT use any skincare products that have not been approved by your licensed esthetician or physician. Your treatment was finished with IMAGE products that are safe to be left on your skin for the evening. You may start your POST TREATMENT KIT the next morning.
I understand and agree to only use the products in my Post-Peel Kit (unless otherwise directed by your esthetician or physician) for days 1-7 following the chemical peel to prevent skin damage.*

Yes
No aerobic exercise and/or vigorous physical activity for 48 hours.*

I have read and understand this policy
No direct sunlight exposure for 24 hours following the treatment (including any strong UV light exposure and/or tanning beds).*

I have read and understand this policy
If some sun exposure cannot be avoided, apply a broad spectrum sunscreen of at least SPF 30. Sunscreen (with a minimum SPF 15) 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.*

I agree to adhere to this policy
Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer.*

I agree to adhere to this policy
DO NOT apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity.*

I agree to adhere to this policy
Consult your skin care professional before resuming topical treatments such as gels or spot treatments.*

I agree to adhere to this policy
This treatment may 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.*

I agree to adhere to this policy
Cancellation Policy
A valid credit card is required to book all appointments. In the event of cancellations received less than 24 hours prior to appointment, a cancellation fee equal to the reserved service booking will incur; Saturday cancellations require 48 hour notice. No Shows will be charged 100%*

I understand the reservation and cancellation policies at Crazy Beautiful Spa and consent to my credit card on file being charged if I fail to give proper notice when cancelling.
Liability Waiver
It is my choice to recieve spa treatments. I realize that the treatment is being given for the well being of my body and mind. I agree to communicate with my service provider any time I feel as though my well-being is being compromised. I understand that the service providers do not diagnose illness, disease, or any physical or mental disorder, nor do they prescrible medical treatment, or pharmaceuticals. I acknowledge that spa services are not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I have stated all medical conditions that I am aware of, and will update the service provider of any changes in my health status. I understand that all employees of Crazy Beautiful Spa are licensed professionals, and that by law they have the right to refuse service on any client at any time, if they feel as though their well-being is comproised.

I understand and voluntairly accept the risks associated with the facial and/or any other services, including but not limited to: facials, hair removal, tinting, henna, lash extensions, lash lifting and all other services provided by the spa. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from treatment at Crazy Beautiful Spa. I agree Crazy Beautiful Spa will not be liable for death or any injury, including, without limitation, personal, bodily or mental injury, economic loss or damage to me resulting from negligence, other acts in Crazy Beautiful Spa, anyone acting on Crazy Beautiful Spa’s behalf, to the fullest extent permited by law. This agreement together with Crazy Beautiful Spa's rules and regulations, constitute the entire agreement and cannot be amended, except in writing by both parties. Myself and/or any of my heirs, executors, representatives, or assignees hereby release Crazy Beautiful Spa from all claims or liabilities for death, personal injury or propery loss or damages of any kind sustained while on the premises, from any advice or services provided by an employee, independent contractor or any representative of Crazy Beautiful Spa.

I understand that Crazy Beautiful Spa is a tranquil and professional environment and that any inappropriate behavior may result in temination of my services and full payment is expected. By signing this form, I agree to the above terms and release Crazy Beautiful Spa and its employees, independent contractors or representatives from any liability.
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Chemical Peel Consultation Form & Waiver

Your Skin

Your Health

Pre-Care Instructions

Post-Care Instructions

Cancellation Policy

Liability Waiver