Client Intake Form

Name*

First NameLast Name

Date*

Date

Date of Birth *

Date

Contact*

Phone #Email Address

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?*

Walked byFacebook/InstagramOnline SearchReferral

If referred, by who?

Type of Service

FacialRelaxation MassageBody ScrubEnergy Work

Any known allergies?*

List medications/supplements you are currently taking.

Have you ever received any botox or fillers? if so, where and when?

What are your skin concerns?

What would you say your skin type is?*

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)

What skin care products do you use on a daily basis?*

Do you experience routine breakouts or acne?

YESNO

Have you been diagnosed with eczema, psoriasis or rosacea?*

YESNO

Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis

Do you currently use:

AccutaneRetin-APrescribed topical cream

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs

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

YES, within the last monthYES, within the last 2-3 monthsNO

Do you?

I acknowledge that I must adhere to Vibrational Earth Body and Skincare policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of a service or 50% of the total service cost. I acknowledge that ANY no show will result in the loss of a service and 100% of the total deposit cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments I release Vibrational Earth Body and Skincare of any liability associated with any injuries and /or current and future conditions resulting from the body and skincare procedures or products.

Signature

Client Intake Form

Your Skin