Intake Form

Skin by Samie and Company

Intake Form
Full Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Check all conditions that apply:

AsthmaCancerActive InfectionHeart ProblemsRecent SurgerySkin DiseasesEpilepsySeizure DisorderEczema/PsoriasisMetal ImplantsPacemakerRosaceaActive AcneDental ImplantsLight SensitivityHormone Imbalance
Allergies or sensitivities:
All oral or topical medications used within the last 3 months:
Any health conditions not listed above or additional information:
Have you used Accutane within the last 12 months?*

YesNo
Have you ever had Botox or any other injectable?*

YesNo
Are you currently pregnant or breastfeeding?*

YesNo
Do you wear contacts?*

YesNo
In the last three months have you used any glycolic acid, salicylic acid, AHAs, BHAs, retin-a, retinol, vitamin a derivative, skin thinning product or any prescribed topicals?*

YesNo
If yes, please list:
Because certain treatments should not be preformed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I understand that Skin by Samie and Company reserves the right to refuse to preform treatments on anyone whom they deem to have a condition for which treatments are contradicted. I understand that estheticians are not qualified to diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of any session given should be constructed as such.

I give permission to Skin by Samie and Company to preform my skincare procedures and will hold her harmless from any liability that may result from any treatment. I understand my esthetician will take every precaution to minimize or eliminate negative reactions. If I experience any pain or discomfort, during or after the treatment, I will immediately inform the esthetician so that the products and/or technique can be adjusted. In the event that I may have additional questions or concerns regarding my treatment or suggested post-treatment care, I will consult Skin by Samie and Company.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs. I understand the procedure and accept the risks. I agree to keep Skin by Samie and Co updated to any changes in my medial profile before any treatment and understand there shall be no liability on the estheticians part if I fail to do so.
Signature*

Clear
Studio Policies

I understand I need to notify Skin by Samie 24-hours in advance, if I need to cancel, reschedule or make changes to an appointment by texting (909) 312-3779 to avoid charges. All appointments must be secured by a valid credit card while booking and fees will be charged to the credit card on file. Clients whom cancel or reschedule less than 24 hours before their appointment will be charged 50% of the scheduled service total. No showing for an appointment will result in a charge of 100% of the appointment. As a courtesy to other guests and the service provider if you communicate that you are running 10 or more minutes behind to your scheduled time your appointment will be rescheduled. 50% of your scheduled services will be charged to the card on file. If you are running late an do not let the provider know you will be considered a now show after the 10 minute grace period.
Initial*

Due to safety hazards present in the environment such as hot wax and chemicals, we are unable to accommodate children under the age of 12 unless they have a scheduled appointment. Our facilities do not have the capacity to accommodate carriers and strollers. Anyone under the age of 18 receiving a service for the first time must have a parent or guardian present at the initial appointment to give written consent.
Initial*
Optional Photo Release

I give permission to Skin by Samie and Company for photographs to be used for client history, educational and/or promotional purposes. I understand that pictures may be taken before, after and during treatments. Complete confidentiality will be maintained at all times.
Initial
Any questions, comments or concerns you'd like your service provider to address before your service:
Should be Empty:

Skin by Samie and Company