Client Intake/Consent Form

  • Client Intake/Consent Form

  • Date of Birth*
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  • Your Medical History

  • Do you have any of the following medical conditions?*

  • Do you have a pacemaker or any metal implants?*
  • Are you being treated for any conditions by a physician or dermatologist?*

  • Your Skin

  • Have you ever had a facial or skin treatment before?*
  • What do you consider your skin type?*
  • Do you use sunscreen?*

  • IF YES TO THE QUESTION ABOVE, PLEASE STOP ALL FORMS OF RETINOL/VITAMIN A PRODUCTS AT LEAST 72 HOURS BEFORE THE FACIAL.

  • Do you have a tendency to redness?*
  • Do you ever experience burning, itching or stinging sensations on your skin?*
  • Do you have any active cold sores or open wounds?*
  • Have you received Botox or filler injections in the past 14 days?*
  • Have you recently received a chemical peel or laser treatment?*

  • Female Clients

  • Are you pregnant or trying to become pregnant?
  • Are you taking birth control?

  • Photo/Video Release

  • I consent to the taking of photographs/videos to be used on social media for portfolio purposes as well as tracking progress in my treatments. I understand I will not receive any financial compensation for photos or videos that may be used as described above.*

  • Authorization

    By signing and submitting this form, I acknowledge, consent and agree to the following:

  • I give my permission to receive facials, skin care treatments or waxing services.

    I understand that my esthetician does not diagnose illnesses or injuries, or prescribe medications.

    I understand, have read, and completed this form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that my data will be strictly confidential. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. I understand that there may be certain risks involved with any treatment and if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

    I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition and lifestyle and there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

    I give consent for all future treatments and I am aware that it is my responsibility to inform my esthetician of any changes to my medical history and/or medications at subsequent visits. I acknowledge that my esthetician holds the right to terminate the session at any time.

    I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my esthetician immediately. 

    I release my esthetician, Mely Guilaran from any and all liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products used and assume full responsibility thereof.

  • Today's Date*
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