Client Form

New Client Intake Form

Thanks for booking at CAZA SEOUL. Please fill out all forms at least 7 days prior to your appointment. (Unless approved by Yamilex R. To do it less than that time frame.) Be advised that your appointment may be rescheduled or canceled if any contraindications apply. I look forward to meeting you!
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Birthday

MonthDayYear
Date
How would you describe your skin type? Check all that apply.
What are your skin concerns? Check all that apply
What is your current relationship with skincare?
Have you been under the care of a dermatologist within the past year. If so, what for?
Do you currently use Accutane, Retin-A, or any other prescription skincare products? Please specify.
Have you received any injectables such as Botox, Juvederm, Dysport, Restylane, etc.? If so, please specify treatment and how long ago.
Do you have any skin diseases/disorders that have been diagnosed by a doctor? Please specify.
Have you received chemical peels, microdermabrasion, dermaplaning, or any other resurfacing treatments? Please specify treatment and how long ago.
Do you have metal implants, pacemaker, or piercings? Please specify.
Do you have any allergies or sensitivities? Please specify.
Are you pregnant, lactating, or trying to become pregnant? Please specify.
List any medications you take regularly.
List any skin treatments, waxing, etc. that you receive regularly.
List any dietary restrictions.
Do you smoke/drink alcoholic beverages /consume caffeine regularly? Please specify.
Do you play sports or workout regularly?
Do you wear makeup regularly?
Do you tan regularly indoors or outdoors?
Do you wear sunscreen regularly? (Not included in makeup)
List all skincare products and brands you are currently using. (Cleansers, Exfoliants, Toners, Serums, Moisturizers, Oils, Masks, SPF, Tools, Etc.) Please be specific.
How often are you using your skincare products?
Are you claustrophobic?
My favorite part of a facial is:
Are there any treatments you’d like more info on?

Other
How did you hear about Yamilex Esthetics LLC?

Other
I give Jaqueline Riestra and Yamilex Esthetics LLC permission to take photo and/or video of me during my service to use for promotional and educational purposes, as well as to keep track of my progress between treatments.
If I experience any pain or discomfort during the session I will immediately inform Yamilex Riestra so that the session may be adjusted to my level of comfort. I further understand that aesthetic treatments should not be considered a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical alignment that I am aware of. I understand that licensed estheticians are not qualified to diagnose, prescribe, or treat any physical or mental illness, and nothing in the course of the session should be constructed as such. Because certain aesthetic treatments should not be performed under certain medical conditions, I affirm that I have stated all my non-medical conditions and answered all questions honestly. I agree to keep CAZA SEOUL and Yamilec Riestra updated as to any changes in medical profile, and I understand that there shall be no liability on CAZA SEOUL or Yamilex Riestra as I should fail to do so.
Are you under 18 years of age?
If you are under the age of 18 please have parent or guardian sign the consent form. Parent or guardian gives the under age permission to receive treatment from Caza Seoul by providing signature.
Full Name(parent or guardian fill name here if signing for minor)
Signature
Date

MonthDayYear
Date
Should be Empty:

New Client Intake Form