CLIENT INTAKE FORM

CLIENT INTAKE FORM
Personal Information
Name*

First NameLast Name
Phone #*
Email*
example@example.com
Medical History
Please be advised that there are certain contraindications (health conditions) that may preclude you from receiving treatments. It is important that you inform us of any medical condition that may not be suitable for body contouring or certain skin treatments, this allows us to make suggestions best suited for our client's and to ensure optimum results and the health and safety of our client's.
Body Contouring treatments may not be suitable for those with Heart Disease, High Blood Pressure, Liver or Kidney Disease, Colon/ Pancreas/ Gallbladder Disease, Cancer/Tumors, Skin Disorders or recent Skin Infections, Auto Immune Disorders, Lupus, Arthritis, Epilepsy, Acute Vascular Thrombosis, those with Metal Implants, Pacemakers, Wires, Defibrillators, and those who are Pregnant. Do you have any of the medical conditions listed above?*

YesNo
If yes, please specify:
Do you have any of the skin conditions listed below?*

EczemaPsoriasisRosaceaAcneMelasmaVitiligoCold SoresKeratosis PilarisKeloid SkinFolliculitisOtherDoes not apply
If other, please specify:
Do you currently struggle with Polycystic Ovary Syndrome (PCOS) or any other hormonal disorders?

YesNo
Are you currently pregnant, breastfeeding, menopausal, or taking birth control?

YesNo
Are you currently under the care of a Dermatologist?*

YesNo
If yes, please specify:
Do you currently take any topical or oral acne medications or have in the last 6 months?*

AccutaneRetin-A or RetinoidsDifferinOtherDoes not apply
If other, please specify:
Do you have any known allergies or sensitivities to the following?*

AspirinTree Nuts/ AlmondsFruitsVegetablesDairySugarcaneIodineLatexGelsFragrances or Essential OilsScrubsLidocaine/ Numbing CreamBeeswaxOtherDoes not apply
Do you have any known allergies or sensitivities to any skincare ingredients?*

Glycolic AcidSalicylic AcidLactic AcidMandelic AcidMalic AcidCitric AcidTartaric AcidBenzoyl PeroxideRetinolVitamin COtherDoes not apply
If other, please specify
Do you have any allergies to any skincare brands?*

YesNo
If yes, please specify:
Have you had any cosmetic/ medical surgery in the last 6 months?*

YesNo
Do you spend significant times in the Sun (Leisure, Work, Outdoor activists, etc)?*

YesNo
Do you Sun bathe/tan or use tanning beds?*

YesNo
What are your skin concerns?*

AcneHyperpigmentationDark spotsFine line or WrinklesAcne scarringMelasmaAge spotsBlackheads or WhiteheadsOther
If other, please specify:
What skincare products are you currently using?*

CleansersTonersExfoliants/ ScrubsSerumsOilsMoisturizersSPFOther
If other, please specify:
Do you currently use any of these active ingredients?*

RetinolVitamin A derivativeHyaluronic acidVitamin CAHA’s (Glycolic, Lactic, Mandelic acids)BHA (Salicylic acid)Benzoyl PeroxideKojic acidHydroquinoneOtherDoes not apply
Have you ever received any of the following skincare services?*

FacialsDermaplaningLed therapyHydradermabrasionMicrodermabrasionAlgae/ Green peelsChemical peelsMicroneedlingHigh FrequencyDoes not apply
Release of Liability Waiver
• I have been honest and forthright about my medical and skin history, and I am healthy to receive the skin care and body contouring treatments being provided.*
• I understand that any medical condition may preclude me from receiving any treatments and if I choose to proceed with any treatments without consulting my primary physician or medical professional will be done at my own risk and I will assume full responsibility for personal injury, adverse reactions, and/or exacerbation of any medical conditions. *
• I understand that TIMELESS BEAUTY STUDIOS does not identify, diagnose or offer any treatments for any medical conditions/ diseases. I further understand that Body Contouring does not treat any medical conditions nor does it claim to treat or relieve any medical conditions. *
• I understand that TIMELESS BEAUTY STUDIOS and their providers are performing services for me that are related specifically and only to the cosmetic improvement of my appearance, and is not a dermatology or plastic surgery practice. *
• I certify that the preceding personal, medical, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician or specialist of my current medical or health conditions and to update this history. A current medical history is essential for the aesthetician / technician to execute appropriate treatments.*
I declare that I am of legal age and I give my consent to Timeless Beauty Studios to perform any present and future Skincare and/or Body Contouring treatments discussed. I have carefully read and fully understand the contents provided herein and I assume full responsibility of the risks involved, including any complications and benefits resulting from the foregoing. I release Timeless Beauty Studios and its staff of any liability associated with any injuries to me, including, but not limited to, personal bodily injury, death, mental injury, economic loss or any damage to me, my spouse, or relatives resulting from any of the services provided. *
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CLIENT INTAKE FORM

Personal Information

Medical History

Release of Liability Waiver