New Client Consultation Form

New Client Treatment Waiver

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge. All information will remain private & confidential.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

City

Country
Phone Number*

PrefixPhone Number
E-mail*
Emergency Contact Name & Mobile
How did you hear about us?*

InstagramFacebookGoogleFriend/ReferralOther
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / Rosacea / SensitivityAgingBreakoutsDry / FlakyExcess OilOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when, what treatment and how long ago?
What’s something you mainly want to focus on during your facial? Ex: Relaxation, Extractions, Everything/ Experience as a whole :) Please let us know so we can best accommodate your needs!
What Skin Care Products do you currently use?*

Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Preferred Brand(s)
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these facial services in the last 14 days?*

Electrolysis / LaserBotox / Dermal Fillers / Facial InjectablesNone
If yes, please confirm last date

MonthDayYear
Date
Your Health
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold Sores (please note you cannot have any present cold sores at the time of your treatment)HIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesCovid-19OtherNone
If you checked yes to any of these please provide further information. If not mark N/A*
Do you?*

Wear contact lensesWear hearing aidsHave metal implantsHave a pacemakerNo, not applicable
Do you take any dietary / health supplements?

YesNo
If yes, please list
Any known allergies? (aspirin, nuts, fruits, shellfish, essential oils etc) Please note: there is a dog on premise, but won't be in the room at the time of your service*

YesNo
If yes, please give details
Have you currently taken any prescription / over the counter medications*

YesNo
If yes, please give details
What is your daily water intake (glasses / litres)*
Have you ever experienced claustrophobia? *

YesNo
Are you sensitive to light?

YesNo
Please rate your stress level*

LowMediumHigh
FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause issues? *

YesNoN/A
If yes, please specify
Is there any other information you would like to make your esthetician aware of? If yes, please give details:
Pre Facial Advice: Please avoid the use of any exfoliants 3 days before your appt. Injections (botox/filler) must be 2 weeks done 2 weeks before your facial. Post Facial Advice: 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. Facial massage, gua sha, chemical peels, enzyme peels, microcurrent, and radio frequency may cause temporary redness/pinking of the skin - this is a normal and positive outcome and indicates the increase of bloodflow as a result of the treatment. Otherwise all pinking should subside within a few hours. If you have any concerns about this please let me know prior to the treatment. Please do keep in mind that there is a possibility that you may break out after the facial. This is completely normal and is called purging. Since the facial is very stimulating it is bringing all the pimples up to the surface, it's just part of the healing process! For the next 3 days keep to a simple skin care routine. A gentle cleanse, moisturizer and SPF 30 or higher are a must. Do not apply exfoliating ingredient / products as well as retinol 7 days after your service as over-exfoliation, can result in irritation or further sensitivity. Do NOT pick peel or scratch your skin as it may cause damage or compromise your results. If you have any concerns post treatment please contact me. We cannot guarantee absolute outcomes, as individual reactions to treatment can vary. By choosing to undergo a treatment, you acknowledge and assume responsibility for any potential outcomes or reactions that may arise, We encourage open communication and will do our best to address any concerns you may have throughout your treatment. Please be aware that as estheticians, we are not registered massage therapists (RMTs). Our specialty lies in relaxation/Swedish massage techniques. While we can adjust the pressure to your preference, we must do so within reasonable limits, given our training as non-RMTs. We want to assure you that we prioritize the safety and well-being of our clients above all else. Please be assured that are fully committed to maintaining the highest standard of care and safety. Our estheticians are well trained and we strictly adhere to industry best practices.*

I have read and agree to adhere to them.
Reservation & Cancellation Policy for all current and future appointments: A $30 non refundable deposit is needed when booking any appointment and will go towards your treatment. You will not be charged an additional $30 fee if you decide to reschedule only. Reschedules must be made 48 hours before your appointment, if done after the 48 hours this will be considered a late cancellation/reschedule and you will be required to pay an additional $30 fee for any new appointment. If you are running late please let us know ASAP! A late arrival can take away from your treatment time. All treatments must end according your booked time time to ensure fairness to others. Any flu like symptoms or suspected Covid-19 is the exception to this rule, but please do let me know asap!*

I understand the reservation and cancellation policies at Clear Complexions Co and consent to my credit card on file being charged if I fail to give the required notice.
Payments: All bookings are required to pay a $30 non refundable deposit when booking your appointment.

Payment Options:

1. Credit/Debit (Processing fee + GST

2. Cash (please bring exact amount, no change) no fee
Do you give Clear Complexions Co. permission to post photos/short video clips of you on their social media?

YesNo
CLIENT DECLARATION: I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand I must communicate any new changes to my health assessment form to my esthetician. I understand that redness and other reactions may occur from facial treatments. If I experience any discomfort during the treatment I will inform my esthetician immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the therapy from liability and assume full responsibility thereof.*

I understand
Signature*
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New Client Treatment Waiver

Your Skin

Your Health