Client Intake/Consent Form

Name*

First NameLast Name

Date of Birth*

Phone Number*

Area CodePhone Number

Email

Occupation

Are you currently taking any supplements/vitamins or medications (such as antibiotics, blood thinners, acne medications/anything from a dermatologist, etc.)? If yes, please list below:*

Do you have any known allergies/skin sensitivities? If so, please specify below:*

Do you have any of the following medical conditions?*

Do you have a pacemaker or any metal implants?*

YesNo

Are you being treated for any conditions by a physician or dermatologist?*

YesNo

Did you undergo any major surgery in the past 90 days? If yes, please describe:*

Have you ever had a facial or skin treatment before?*

YesNo

If yes, when?

What do you consider your skin type?*

Normal (no visible blemishes, fine pores, smooth texture)Dry (dull, visible lines/wrinkles, tightness, rough texture)Oily (enlarged pores, excess oil, uneven texture)Combination (oily and dry patches, oily t-zone, hormonal acne)Not sure

What are your specific skin care concerns or challenges with your skin?*

What does your daily skin care regimen consist of? Please list products you are currently using:*

Do you use sunscreen?*

AlwaysSometimesNever

Are you currently using any form of Retinol/Vitamin A (Tretinoin, Adapalene, etc.) or any topical prescription medication? If so, please list below:*

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?*

YesNo

Do you ever experience burning, itching or stinging sensations on your skin?*

YesNo

Do you have any active cold sores or open wounds?*

YesNo

Have you received Botox or filler injections in the past 14 days?*

YesNo

Have you recently received a chemical peel or laser treatment?*

Yes - in the last monthYes - in the last 2-3 monthsNo

Are you pregnant or trying to become pregnant?

YesNoRecently had a baby and nursing

Are you taking birth control?

YesNo

If yes, please list what kind:

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.*

Yes, I give full permission and understand the conditions.No, I do not give my permission for any photos or videos to be taken.

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.

Signature *

First NameLast Name

Today's Date*

Client Intake/Consent Form

Your Medical History

Your Skin

Female Clients

Photo/Video Release

Authorization