New Client Consultation Form

Name

First NameLast Name

Date

MonthDayYear

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Please indicate your gender

Leave it blank if you Prefer not to mention

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

How did you hear about me?

If Referral, please list name

If Other, please let me know

What are your skin care goals?

What are your skin care challenges?

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?

If Yes, when?

**If you are seeking corrective treatments please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skincare goals.

What Skin Care Products do you currently use?

Please mention the specific products you are using.

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Please specify which product or type, if you answered 'Yes, currently using' to above.

Have you received any of these hair removal services in the last 30 days?

If checked, please note last time.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?

Environ DF Facial (Ionzyme Technology) :Please check if you have:

If yes, provide details:

DMK Enzyme Therapy : Please disclose if you have

If yes, provide details:

DMK Treatment Acknowledgement:

Please put your initials:

Have you had a brow lamination, brow tint, lash lift, or lash tint before?*

If yes, when was your last service and where?

Have you ever had an allergic or adverse reaction to any brow or lash chemical treatment (lamination solution, perming solution, tint/dye, adhesive, or developer)?*

If yes, please describe the reaction and product involved:

Have you had a patch test for brow tint within the last 6 months?*

Do you currently have any of the following in or around the brow area?*

Have you had any of the following brow treatments in the last 4 weeks?*

Are you currently using any retinoids, AHAs, BHAs, or exfoliating products around the brow area?*

If yes, please specify product and when you last applied it:

What is your desired brow look?

Preferred tint shade (if applicable):

Have you experienced any of these health conditions in the past or present?

If you checked yes to any of these please provide further information. If not mark N/A

Do you?

Do you take any of the following dietary / health supplements?

If other, please list

Any known allergies?

If Other, please specify

Have you used or been prescribed any medications (topical or oral) for acne / acne control?

If yes, please specify what and date last used

Are you a smoker?

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

Have you ever experienced claustrophobia?

Please rate your stress level

Please let me know if you would like to learn about natural ways to lower stress levels

FEMALE CLIENTS

Are you taking birth control?

If yes, what kind

Are you pregnant or trying to become pregnant?

Any menopause issues?

If yes, please specify

Are you undergoing any hormone replacement therapy?

If yes, please specify

MALE CLIENTS

What is your current shaving system?

Do you experience irritation from shaving?

You allow Micromoon Skin Studio to capture the before and after photographs during the consultations and treatment time. You understand that these images will be securely stored in you client file and will not be shared without my explicit consent.

Initials required

I give MicroMoon Skin Studio permission for my photos to be used for education.

I give MicroMoon Skin Studio permission for my photos to be used for advertising .(Website, Marketing, adds, Instagram, tiktok, and Facebook).

The following waiver of all claims, release from all liability, assumption of all risks, agreement not to sue, and other terms of this agreement are all entered into by me.

I acknowledge I have been allowed to ask any questions I may have, and those questions have been answered.

initials required

I understand my Esthetician/Technician will take every precaution to minimize or eliminate negative reactions as much as possible, and I agree to inform my Esthetician/Technician if I experience any pain, discomfort, or sensitivities during treatment, allowing for them to make the appropriate adjustments.

initials required

I certify that I have read and fully understand the contents of this consent form, I have been sufficiently informed of the benefits and risks involved with treatment, that I am at least 18 years of age, and that I am fully competent to give my consent.

initials required

If you’re not 18 years old, then the guardian has to sign this section to take responsibility for the treatment decision.

Please write your full name

I do not hold the Esthetician or her staff, who did the treatment, responsible for any of my present conditions, but not disclosed at the time of this procedure that may be affected by the treatment performed today. I agree to hold my Esthetician/Technician, her staff and Micromoon Skin Studio not liable for any damages, injuries, or claims that may result from this treatment/procedure.

initials required

I am aware that there are inherent and significant dangers, hazards and risks associated with the service. I am aware that the Risks include but are not limited to injury from physical equipments, products used, performing a skill incorrectly, or potentially any obstacles, conditions on the floor or anything in the environment

initials required

I acknowledge my obligation to inform the esthetician if I feel any pain, discomfort, fatigue or any other symptoms. I understand that I can stop the treatment any time, and have the right to immediately leave the space.

initials required

I understand and accept that with any treatment, there may be some risks involved. I trust that the estheticians and staff have taken every possible precaution to ensure a safe and positive experience. While every effort has been made to minimize any risks, some elements may still be beyond complete control. By proceeding with this treatment, I accept responsibility for my own well-being and agree to move forward with full awareness and understanding. I appreciate the care and expertise provided and acknowledge this waiver as part of the safety measures in place. Thank you for your trust.

initials required

In consideration of receiving services from MicroMoon Skin Studio LTD, I acknowledge and agree to the following: a) I understand that, by participating in this treatment, I am choosing to waive any claims that I or my legal representatives may have now or in the future regarding this experience. b) I release and discharge MicroMoon Skin Studio LTD from any potential liability related to personal injury, property loss, or other concerns resulting from this treatment. This includes any possible issues due to factors such as negligence, legal obligations, contract terms, or other professional judgments made by the company or esthetician.

initials required

I understand that by receiving treatments at Micromoon Skin Studio, I agree to take responsibility for any issues that may arise. I also agree that Micromoon Skin Studio, along with its team, is protected from any claims or liabilities connected to my treatment. Thank you for helping us create a safe and positive experience together.

initials required

I confirm that I have had sufficient time to read and understand each term in this waiver in its entirety, and have agreed to the terms freely and voluntarily. I duly authorize the Esthetician/Technician to perform the treatment on me, as well as any post-treatment requirements that may be necessary. I understand that this waiver is binding on myself and my Legal Representative.

initials required

I understand that brow lamination involves the use of chemical solutions to reshape brow hairs, and that brow tinting uses semi-permanent dye around the delicate eye area. I acknowledge the following potential risks: mild redness, irritation, swelling, allergic reaction, uneven results, or temporary hair texture change. I confirm I have disclosed all relevant information above and will follow all pre-care and post-care instructions provided by my Esthetician. *Initials required:

Initials required:

Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of 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. 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. Enzyme peels, DermaFile or DermaDisc 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.

Reservation & Cancellation Policy

To respect our time and other clients, the following policies apply to all bookings at Micromoon Skin Studio LTD.

Deposit
• A $50 deposit is required to secure all appointments.
• Deposits are non-refundable.
• Deposits are applied toward your service total if cancellation terms are respected.

Appointment Confirmation

• Please confirm your appointment when you receive a reminder from Square or our team.
• Unconfirmed appointments may be released.

Cancellations & Rescheduling

• A minimum of 48 hours (2 days) notice is required to cancel or reschedule.
• Changes made less than 48 hours before your appointment will result in the deposit being forfeited.
• A new deposit will be required to rebook.

Same-Day Cancellations & No-Shows

• Same-day cancellations, changes, or no-shows will result in 100% of the service cost being charged.
• Payment is required within 12 hours of the original appointment time.

Card on File Authorization

By booking an appointment and providing a credit card on file, you authorize Micromoon Skin Studio LTD to charge your card according to this policy.

Please put your initials:

Signature

New Client Consultation Form

Let's talk about your Skin

ADVANCED TREATMENT DISCLOSURE

BROW LAMINATION & TINT CONSULTATION

Your Health

Photo Consent and Release

Acknowledgement of Risks and Liability

Brow Lamination & Tint Acknowledgement

Post Care and Cancellation Policy